Endo

7
Endodontic
Armamentarium
ADHAM A. AZIM AND PHILIP MICHAELSON
CHAPTER OUTLINE
Introduction, 117 Nonsurgical Root Canal Treatment, 120
Examination and Diagnosis, 118 Instrumentation Armamentarium, 121
Magnification, 119 Coronal Seal, 129
Isolation, 119 Surgical Armamentarium, 130
LEARNING OBJECTIVES
At the end of this chapter, the student should be able to: 5. Explain the basis for sizing and taper of hand and rotary instru-
1. Define the basic set of armamentarium appropriate for diagno- ments.
sis, emergency treatment, canal preparation, obturation, and 6. Describe the basic design of the more common canal prepara-
endodontic surgery. tion instruments and their mode of use.
2. Describe the general characteristics of endodontic armamen- 7. Describe the various adjunct tools needed to achieve adequate
tarium and show how these characteristics are related to their disinfection.
use. 8. Identify the various temporary restorative materials used after
3. Describe the importance of using magnification for proper endodontic treatment.
endodontic treatment. 9. Describe the various adjunct tools used during endodontic
4. Present the advantages of three-dimensional (3D) versus two- surgery.
dimensional (2D) radiographic imaging.
Introduction the dental pulp. Over the next several decades, endodontic instru-
ments continued to evolve into the instruments and materials we
The goals of nonsurgical root canal therapy (RCT) are to chemo- use today. Over the past two decades, the endodontic armamen-
mechanically débride, disinfect, and shape the root canal spaces, tarium has undergone major renovations in nonsurgical and surgi-
followed by adequately sealing all portals of entry and exit.1,2 To cal treatment that have allowed endodontic treatment to become
achieve these goals, multitudes of solutions and dental instru- more successful.
ments have been specially designed and used. Historically, varied This chapter provides an overview of basic and advanced
attempts at endodontic treatments have been documented since endodontic armamentarium and describes their use in the clinical
ancient times. In 1728 Pierre Fauchard wrote The Surgeon Dentist, setting. Proper knowledge of the various instruments, materials,
which described the dental pulp space and the procedure to access and equipment, together with their design, composition, and
this space to relieve abscess formation. Fauchard recommended function, is critical to provide patients with proper diagnosis and
leaving the access to the pulp space open for months and then fill- treatment options. The field of endodontics is constantly evolving
ing the opening with lead foil. Advancing on this concept, Robert with improved armamentarium to assist clinicians with diagno-
Woofendale in 1766 was credited with the first endodontic proce- sis and treatment. Clinicians should always consider using newer
dure in the United States. He would cauterize the dental pulp with instruments, materials, and equipment to provide the best pos-
a hot instrument and place cotton in the root canals. From this sible treatment for their patients. It will not be possible to include
idea, the concept of pulp extirpation took hold. In 1838 Edwin all armamentarium used in every endodontic procedure in this
Maynard fabricated the first endodontic instrument. He ground a chapter. However, the most widely used instruments and materials
watch spring into a broach, which he would then use to extirpate will be covered in detail.␣
117
118 C HA P T E R 7 Endodontic Armamentarium
Examination and Diagnosis

Clinical Examination
The primary aim during endodontic diagnosis is to determine the
vitality of the pulp and the status of the supporting periodontal
structure. For that, clinicians use a basic examination kit, which is
very similar to instruments used for restorative dentistry. It is com-
posed of a mouth mirror, Shepherd’s hook explorer, periodontal
probe, and cotton pliers (Fig. 7.1). The vitality of the dental pulp
is routinely examined using sensibility tests that aim to stimulate
the pulp through temperature (cold or hot) or electric stimulation
Electric pulp testing used to determine pulp vitality.
(Figs. 7.2 and 7.3). The supporting periapical tissues can be exam-
ined with the back of the mirror (percussion), the index finger
(palpation), and the periodontal probe. Other instruments can be
used to determine the presence or absence of a coronal crack or a
root fracture, such as a “Tooth Slooth,” a transilluminator, methy-
lene blue, or caries detection dye.␣
Radiographic Examination
Radiographic examination is the key diagnostic tool used to eval-
uate the periapex. Different types of radiographs can be used for
endodontic diagnosis. Two-dimensional (2D) intraoral radiographs,
periapical and bitewing, are used to evaluate the teeth, their sup-
Examination kit containing a mouth mirror, periodontal probe, porting structures, and any existing restorations. Three-dimensional
dental probe, and cotton pliers. (3D) radiographs and cone beam computed tomography (CBCT)
have become routinely used in endodontic diagnosis due to their
ability to provide 3D images of the area of interest. In 2017 a sur-
vey sent to members of the American Association of Endodontists
(AAE) showed that almost 50% of the endodontists in the United
States have a CBCT machine in their offices.3 CBCT use among
endodontists is increasing because it can further assist clinicians in
proper diagnosis and treatment planning.4-8 Rodriguez et al.7 inves-
tigated the influence of CBCT imaging on clinical decision-making
choices of different specialists among cases with different levels of
difficulty. The results showed that examiners altered their treatment
plan after viewing the CBCT scan in 27.3% of the cases and up
to 52.9% in high-difficulty-level cases. Although periapical radio-
graphs are still used as the standard radiographic technique for end-
odontic diagnosis and treatment, there are several clinical situations
in which 2D radiographs may not be able to properly assess the
clinical condition. Periapical lesions have to reach a certain size and
erode the inner cortical plates of the jaws to be visible on a periapical
radiograph.9,10 In addition, 2D radiographs have significant limita-
tions in the detection, assessment, and treatment planning of exter-
nal cervical root resorption compared with CBCT imaging.6 In a
joint statement by the AAE and the American Association of Oral
and Maxillofacial Radiology (AAOMR),11 they outlined several cir-
cumstances in which CBCT can be very useful for better clinical
examination (see Chapter 3). These conditions include cases with
external and internal resorptive defects, trauma and fracture cases,
presurgical treatment planning, and vertical root fracture cases. In
EndoIce used for cold testing. addition, they recommend using CBCT to evaluate the nonhealing
CHAPTER 7 Endodontic Armamentarium 119
Illustration of the use of the dental operating microscope to detect cracks within the crown and
root. (Courtesy Dr. Hajar Albanian.)
of previous endodontic treatment, in intra-appointment identifica- surgery.16,17 In addition to allowing excellent visualization, it is
tion and localization of calcified canals, for initial treatments with a great tool for documentation as well. Clinicians can easily take
potential existence of extra canals and suspected complex morphol- images and videos of the various procedures and use them for bet-
ogy, and for the diagnosis of patients who present with contradic- ter patient communication and education (Fig. 7.4) (Video 7.1).␣
tory or nonspecific clinical signs and symptoms associated with
untreated or previously endodontically treated teeth. It should be Isolation
noted, however, that the accuracy of CBCT relies to a great extent
on the specifications and settings of the equipment used (field of In 1862 Dr. Sanford Barnum developed the rubber dam to allow a
view, voxel size, and artifact correction). Additionally, some lesions saliva-free field in the mouth. Later, Dr. G. A. Bowman improved
may not be accurately detected if they are smaller than 1.4 mm in the rubber dam by inventing the rubber dam clamp, which
diameter.5␣ allowed the stabilization of the rubber dam to a tooth. The rub-
ber dam is intended to isolate the tooth/teeth to be treated from
Magnification the oral cavity to ensure no microbial contamination. In addition,
it offers other kinds of benefits, such as enhancing visualization,
The dental operating microscope (DOM) is considered standard providing a clean operative field, and preventing ingestion or aspi-
equipment in the endodontic office. Before the early 1990s, den- ration of any instrument, material, or irrigant during treatment.
tal loops were used for magnification. The loops were limiting in The 2010 AAE Position Statement on Dental Dams indicated that
two ways: first, only low-level magnification was possible; second, “tooth isolation using the dental dam is ... integral and essential
because the practitioner had to wear the loops, neck strain and for any nonsurgical endodontic treatment.” It is also considered
postural problems often resulted. A web-based survey sent to the standard of care in today’s practice.
AAE members in 200712 showed that 90% of endodontists were An isolation kit is composed of (1) clamps that clasp the tooth
using a DOM during treatment in comparison with only 52% in and are available in different shapes and sizes, depending on the
1999. The clinician can better visualize the root canal anatomy tooth to be isolated (Fig. 7.5); (2) rubber dam sheet, a physical bar-
as a result of the magnification and illumination provided by the rier to isolate the tooth from the oral cavity; (3) rubber dam hole
DOM. Khalighinejad et al. showed that maxillary first molars punch used to create a hole in the rubber dam sheet that allows for
with nonhealed RCT in which DOM was not used were signifi- placement of the rubber dam clamp; and (4) a rubber dam frame
cantly more likely to have a missed MB2 canal in the affected MB used to hold the rubber dam sheet in place (Fig. 7.6). In some
root. This study indirectly shows the value of using the DOM clinical cases, rubber dam placement alone may not sufficiently
on the outcome of nonsurgical root canal treatment, at least in allow adequate isolation of the tooth before initiating treatment.
this situation.13 Other studies also showed that practitioners were Supplementary material such as OraSeal or OpalDam (Ultradent
better able to locate and negotiate canals when the DOM was Products, Inc., South Jordan, Utah, USA) may be applied around
used.14,15 Although dental loops can be used during endodontic the tooth/clamp junction to enhance tooth isolation (Fig. 7.7). In
treatment, the DOM offers multiple advantages: a wider field of clinical cases in which an extensive amount of tooth structure is
view, improved illumination, and less physical strain on the prac- lost, restoration of the tooth to allow for proper isolation is rec-
titioner. DOM is also among the instruments and materials that ommended. This restoration can be achieved using glass ionomer
have significantly improved the treatment outcome of endodontic or composite restorative materials (Fig. 7.8). If placing a clamp
Different types of clamps that can be used for rubber dam isolation, depending on the tooth
morphology.
Rubber dam kit composed of (from left to right) clamp holder, rubber dam punch, rubber dam
frame (white), and rubber dam sheet.
on the tooth might result in damage of an existing restoration, a (Fig. 7.11); (4) endodontic spreaders, used for lateral condensa-
dental dam stabilizing cord, such as Wedjets (Coltene/Whaledent tion of gutta-percha; and (5) endodontic pluggers, used for vertical
GmbH), can be used to stabilize the rubber dam in place without gutta-percha condensation during obturation. Endodontic spread-
the use of a clamp (Fig. 7.9).␣ ers and pluggers come in different sizes as well as both finger and
handle design (Figs. 7.11 and 7.12). Finally, the cassette includes
a metal or plastic instrument that is used to place the temporary
Nonsurgical Root Canal Treatment filling into the pulp chamber.␣
Nonsurgical Cassette
Length Determination
The nonsurgical treatment cassette includes all the instruments
that are needed during RCT (Fig. 7.10). The cassette contains To ensure proper length control during root canal treatment,
the instruments used in diagnosis in addition to other proce- electronic apex locators (EAL) have been used to determine the
dure-specific instruments, such as (1) local anesthesia syringe; position of the apical foramen and/or constriction and thus the
(2) endodontic explorer (DG 16), an instrument that aids in the apical extent for root canal instrumentations. The first EAL was
identification of root canal orifices; (3) a ruler used to measure the introduced in 1962 by Sunada.18 Since their development, EAL
instruments for length control during the root canal procedure have evolved to improve their accuracy and reliability in the
Images illustrating the use of further isolation after rubber dam placement. Lower left: Isolation
using OraSeal putty (Ultradent). Lower right: OpalDam (Ultradent).
various clinical conditions. Currently, EAL are consistently used tooth. Ceramic restorations and porcelain are best approached using
by endodontists and widely used by general dentists.19 EAL have diamonds burs. Carbide burs are acceptable for metal (amalgam,
been shown to be more accurate than standard 2D radiographs gold, crown undercasting) and composite restoration.24 The typical
in working length determination.20 When use of EAL is com- armamentarium consists of sizes 2, 4, and 6 round diamond burs
bined with a radiograph, clinicians can reduce the risk of over- or and size 4 round carbide or #1157 carbide burs. After achieving
underinstrumentation during root canal treatment,21 and thereby access to the pulp chamber, safe end burs (Endo Z) can be used to
achieve more predictable results.22,23␣ avoid any unnecessary damage to the floor of the pulp chamber.
Additional instruments are sometimes required to localize the
root canal orifices/canals (Fig. 7.13). Root canal localization can
Instrumentation Armamentarium be complicated by calcification in the form of pulp stones and dys-
trophic calcification of the root canal space. To remove these calci-
Endodontic Access fied structures, Munce burs, Mueller burs, or Swiss LN burs can
The endodontic access is the opening in the crown of the tooth that be used. They are long shanked rotary burs that can be used for
allows for localization of the root canal space. Classically, the outline precise troughing to expose root canal orifices. These burs come
form for the access has been governed by G. V. Black’s principles of in different sizes to facilitate drilling at different levels without the
cavity preparation. However, the access for each tooth should be root canal space and are used without water coolant, which can
directed by the anatomy of both the pulp chamber and the curva- generate a significant amount of debris. Specialized endodontic
ture of the root. Existing restorations and decay can alter the outline ultrasonic tips can also be used for root canal localization. The
form of the access. Due to the implementation of the DOM, mod- advantages of ultrasonic tips are that they can be used very pre-
ern endodontic accesses can be smaller and more precise in their cisely and, if desired, used with water irrigation. Irrigants, dyes,
location on the crown of the tooth. The access is prepared using a and light can also help in root canal localization. A drop of sodium
high-speed handpiece and burs with water coolant. The selection hypochlorite (NaOCl) can be placed in the pulp chamber and
of burs for access depends on the material(s) in the crown of the viewed under the DOM. The solution will often bubble and “light
Images illustrating the prebuildup using composite resin after removal of the old restoration and
before initiating root canal treatment. (Courtesy Dr. Howard H Wang.)
Clampless rubber dam isolation using Wedjet in an upper anterior tooth with an all-ceramic
crown. (Courtesy Dr. Elham Shadmehr.)
Nonsurgical cassette used for endodontic treatment.
up” a canal orifice. Caries detection dye or other stains can also disinfection is removing all pulp tissue and infected debris from
locate hard-to-find root canal orifices. Transillumination of the the root canal system. Because achieving a sterile environment is
pulp chamber with a curing light has also been suggested to help currently impossible, the root canal space is then filled with a spe-
locate root canal orifices. In summary, precise endodontic access is cial filling material to “entomb” any remaining bacteria. Root canal
essential to a successful root canal treatment.␣ disinfection is achieved through a step called “cleaning and shap-
ing.” Although the primary goal is only cleaning, the root canal
space needs to be shaped by endodontic instruments to facilitate
Cleaning and Shaping Instruments the cleaning process. It should be noted that the current disinfec-
Once access to the root canal system has been achieved, disinfection process derives from the instruments and materials currently
tion of the root canal space can be initiated. The goal of root canal used. With the advancement in technology, noninstrumentation
techniques may be used, and the need to further shape the canal to the treatment. An illustration of the different hand instrument
facilities cleaning may be no longer needed. Cleaning and shaping is shown in Fig. 7.16. The application and use of each of these
of the root canal space with the current endodontic armamen- instruments will be discussed in detail in Chapter 14. The taper
tarium have two primary objectives: (1) the enlargement of the for a standardized instrument is constant for the full length of
root canal space, and (2) creation of a space amenable to the fill- the cutting flutes (typically 16 mm). The taper of the instrument
ing “obturation” method being used. The instruments used for refers to the incremental enlargement of the instrument diameter
cleaning and shaping are classified by the ISO-Federation Den- every 1 mm (Table 7.1). Some rotary endodontic files are variable
taire Internationale. Instruments used by hand only are Group I. in their taper, which means that the taper is not constant for the
Instruments similar to Group I but which are used with a rotary full extent of the cutting flutes and varies for different segments
engine or motor are Group II. Rotary engine–driven drills are of the file.
Group III. All three groups are typically used for an endodontic After an initial glide path has been created, preparation of the
procedure. Initially, small hand files can be inserted to “scout” the coronal and middle thirds of the canal system can be started. A
root canal space. After providing a glide path, rotary instrumen- significant concept in the preparation of the coronal and middle
tation can be commenced. Rotary instrumentation is performed thirds of the canal is called straight-line access. Root canal sys-
using an endodontic electric motor (Fig. 7.14). The electric motor tems are typically similar to an hourglass in shape.25 Straight-line
allows for more precise control of the speed of rotation than that access decreases the curvature in the coronal and middle thirds of
allowed by an air-driven handpiece. Electric motors can also con- the root canal, which favorably preserves the apical curvature. The
trol the allowable torque, which can be set to maximize file perfor- coronal and middle thirds of the canal can be prepared with hand
mance and minimize file separation (breakage). or rotary instrumentation. Traditionally, Hedstrom files were used
Hand and rotary files use standardized systems for sizing and to enlarge the space. Currently, the coronal and middle thirds
identification. The size of a file is defined by 100 times the tip are enlarged with Gates Glidden burs, Peeso reamers, specialized
size. The taper of the file (the increase in diameter from the tip access burs, or nickel-titanium orifice openers. All can be effective
of the file to the handle) is based on 1/100th of a millimeter. The in the coronal enlargement of the root canal system. Gates Glid-
color-coded identification system is based on file size. With the den and Peeso reamers can also be used for the preparation of post
exception of the three smallest file sizes (6, 8, and 10), the color space after completion of RCT (Fig. 7.17). Their use, however,
pattern repeats to aid in file size identification (Fig. 7.15). Hand should be restricted to the coronal and middle third of the canal.
and rotary files come with different cross-sections and accord- Both are available in various sizes (Table 7.2) and lengths. The
ingly can be used in different motions and at different parts of apical third of the canal can be enlarged with hand or rotary files.
The desired final size and taper of the root canal is determined
by the width, curvature, and length of the root. Each root canal
should be individually evaluated for maximum apical prepara-
tion size and taper. The physical attributes of the file (material
and design) dictate its optimal use. The clinician should select
the instrument type based on its mechanical properties and the
desired goal needed to be achieved. Historically, files were made
from carbon steel. Carbon steel had strength but was less flexible
and degraded by sterilization. Stainless steel is used today and has
the benefits of strength, improved flexibility compared with car-
bon steel, and heat tolerance. More recently, nickel titanium has
been used for file fabrication. Nickel titanium allows for strength,
Endodontic ruler. flexibility, ability to withstand sterilization, and the ability to
Hand pluggers in different sizes.

Additional instruments used for canal localization. Long shank round burs in different sizes (left).
Ultrasonic tips with a round diamond tip (right).
required goals. As a result, numerous irrigants are used in mod-

ern endodontic treatment. The advantages and disadvantages of
each irrigant should be considered during each step of endodontic
treatment. Endodontic treatment should then be deconstructed
into sections and the appropriate irrigant used for each step.
Numerous irrigants are used during endodontic therapy. NaOCl
is the most commonly used irrigant in endodontics because it can
dissolve pulp tissue and lubricate the root canals during treat-
ment. In addition, NaOCl is bactericidal and can penetrate deep
Wireless endodontic motor used for endodontic rotary instru- into the dentinal tubules.26-30 Although 2% chlorhexidine (CHX)
ments. has antibacterial effects and is less caustic than NaOCl, CHX can-
not dissolve organic tissue.31-35 Ethylenediaminetetraacetic acid
(EDTA or EDTAC) is used during endodontic treatment due to
tolerate engine-driven rotation. The combination of these char- its ability to chelate inorganic molecules and remove the smear
acteristics allows nickel-titanium engine-driven files to produce layer36; however, it lacks the degree of antibacterial or tissue dis-
a more consistent shape. Ultimately, the combined use of hand solution properties of other irrigants.34,37,38 Sterile saline has been
and engine-driven files is required due to the inherent limitations used to irrigate root canals as well. Baker determined sterile saline
of each individual file. The ability to produce a consistent shape to be an effective irrigant with sufficient volume.39 However, its
allows for more efficacious débridement, disinfection, and obtura- lack of disinfection and tissue dissolution are not ideal.27 Sterile
tion of the root canal system.␣ saline can be used as an intermediary solution between certain
irrigants, such as NaOCl and CHX, to prevent any undesired
Irrigants, Irrigation Devices, and Intracanal chemical interactions.40,41 Other disinfection solutions that con-
tain a mixture of irrigants, such as MTAD and QMix (Dentsply
Medicaments Sirona, Inc., Tulsa, Oklahoma, USA) have been proposed to be
The use of hand and rotary instruments to adequately disinfect used in endodontic treatment. Further discussion on these irrig-
the root canal space should always be performed with an irrigant. ants, their advantages, and drawbacks will be further discussed in
From a conceptual point of view, the ultimate goal of irrigants is to Chapter 14.
provide a disinfected, tissue-free, and debris-free root canal space. In clinical practice, the practitioner must determine the proper
Currently, there is no irrigant that can ultimately achieve all the combination of irrigants and the ultimate concentration needed
for each irrigant on a case-by-case basis. Depending on the status

D0 diameter (in Handle
File # of the pulp and the periapical tissue at the time of treatment, as
mm) Color well as the type of treatment being performed, the combination of
different irrigants can improve the quality of canal débridement.42
06 0.06 Irrigants are commonly delivered in the root canal space using an
irrigation syringe and a small-gauge irrigation needle. Endodontic
08 0.08
irrigation needles range between 25 to 31 gauge. Smaller-diameter
10 0.10 (higher gauge) needles allow greater apical depth and irrigation
delivery in the canal, and thus their use should be considered
15 0.15 during root canal treatment (Fig. 7.18).43-45 Endodontic needles
have various tip designs. They can be open-ended, close-ended, or
20 0.20 side-vented. A side-vented irrigation needle is recommended to
25 0.25
minimize pressure buildup caused by an opened-ended needle and
thus minimize irrigation extrusion into the periapical tissues.46,47
30 0.30 Energetically augmenting an irrigant’s effectiveness has also been
determined to have a positive effect on root canal disinfection.
35 0.35 Devices such as an Endoactivator (Fig. 7.19) can allow sonic acti-
vation of the irrigants through oscillating patterns of nodes and
40 0.40
antinodes.48,49 The use of a small endodontic file on an ultrasonic
45 0.45 handpiece to freely oscillate inside the canal is another form of irri-
gation activation. The transmittal of acoustic energy generating a
50 0.50 rapid movement of fluid in a circular motion (acoustic streaming)
and cavitation through the irrigant can improve its effectiveness.50
55 0.55
Several other methods of irrigation activation will be discussed in
60 0.60 Chapter 14.
With the complete preparation and disinfection of the root
70 0.70 canal system, the final component to nonsurgical endodontic
treatment is obturation of the root canal space. However, in
80 0.80 some clinical situations when treatment is not completed due
to time constraints or inability to achieve a dry canal, intra-
90 0.90
canal medicaments can be placed between visits, which can
100 1.00 also enhance root canal disinfection. Among the intracanal
medicaments used in root canal treatment is calcium hydrox-
110 1.10 ide [Ca(OH)2]. It has antibacterial properties and can assist in
dissolving remaining pulp tissue in the root canal space.51,52
120 1.20
Ca(OH)2 is available in different forms (powder + liquid or
130 1.30 paste). Paste forms can be easily injected into the root canal
space (Video 7.2) or inserted via lentulo spiral (Fig. 7.20) to
140 1.40 allow adequate distribution on to the canal wall. Other medi-
caments, such as 2% CHX gel, can be also used as an intracanal
Color-coding specifications for standardization of files and medicament.␣
reamers.
*Flex R *K–Flex (small) *K–Flex (large) Hedstrom * Unifile

K–Reamer K–Reamer * S–File
(large) (small)
K–File (large) K–File (small)
Longitudinal and cross-sectional shapes of various hand-operated instruments. Note that small
sizes of K-reamers, K-files, and the K-Flex have a different shape than the larger sizes.
TABLE
7.1
Diameter 3 mm from Tip Diameter 3 mm from Tip Diameter 3 mm from Tip
File Size (Color) Tip Size in mm with 02 Taper in mm with 04 Taper in mm with 06 Taper in mm
6 (Pink) .06 .12 .18 .24
8 (Gray) .08 .14 .20 .26
10 (Purple) .10 .16 .22 .28
15 (White)* .15 .21 .27 .33
20 (Yellow)* .20 .26 .32 .38
25 (Red)* .25 .31 .37 .43
30 (Blue)* .30 .36 .42 .48
35 (Green)* .35 .41 .47 .53
40 (Black)* .40 .46 .52 .58
*Color code repeats starting at size 45 files. After size 60, files increase by 10 and not by 5.
TABLE
7.2
Size Gates Glidden Drills Peeso Reamers
No. 1 0.4 mm 0.7 mm
No. 2 0.6 mm 0.9 mm
No. 3 0.8 mm 1.1 mm
No. 4 1.0 mm 1.3 mm
No. 5 1.2 mm 1.5 mm
No. 6 1.4 mm 1.7 mm
condensation (compaction) of the primary gutta-percha cone and

the subsequent placement of additional gutta-percha. In 1933 Dr.
E. A. Jasper introduced silver cones as an obturation material.53
The use of silver cones and cold lateral condensation of gutta-
percha was the primary obturation methods for root canals until
the 1960s. At that time, Dr. Herbert Schilder developed the warm
Left, Gates Glidden drill. Note the noncutting tip and the ellipti-
vertical obturation method.1 This technique included heating a
cal shape. Right, Peeso reamer. Note the noncutting “safe” tip and parallel
sides. These are stiffer and more aggressive than the Gates Glidden drill.
gutta-percha mass and hydraulically compacting the molten mate-
Both are used for straight-line access preparation. rial apically to obturate the pulp canal space. This method would
create an apical seal, but the coronal and middle thirds of the canal
would be devoid of material. The clinician would then continue
Obturation Armamentarium obturating by inserting small pieces of gutta-percha into the root
Obturation of the root canal space is performed to seal the root canal space, heating them, and condensing them, using endodon-
canal space and prevent reinfection.1 As mentioned earlier, Dr. tic pluggers until the entire root canal was obturated. Although
Pierre Fauchard recommended obturating root canals with lead silver cones are not used currently, cold lateral and warm vertical
foil. During the past three centuries, numerous materials were gutta-percha obturation techniques are still commonly used today.
promoted, including but not limited to, gold, plaster of Paris, The armamentarium needed can vary depending on the obtu-
rosin-chloroform, silver nitrate, formocresol, cotton, fiberglass, ration technique used and the complexity of each case. The fol-
calcium hydroxide, silver cones, Hydron, and polyester. In 1867 lowing items are currently the most commonly used:
Dr. G. A. Bowman introduced gutta-percha as a sole root canal 1. Gutta-percha cones are available in different sizes and tapers.
obturation material. In 1925 U. G. Rickert suggested using a Standardized gutta-percha cones correspond to the size and
sealer in conjunction with gutta-percha to improve the obtura- taper of endodontic files used during root canal instrumenta-
tion. This concept was later modified to allow for cold lateral tion. They are also available in a nonstandardized form (fine,
Irrigation syringes containing different irrigation solutions that

can be used during endodontic treatment. From top to bottom: (1) Sodium
hypochlorite (NaOCl), (2) chlorhexidine (CHX), and (3) ethylenediaminetet-
raacetic acid (EDTA).
EndoActivator used for irrigation activation.

The lentulo spiral drill is used to spin calcium hydroxide or
sealer into canals.
fine medium, medium, medium fine, and coarse) that can be
customized for every case.
2. Paper points are used to dry the root canal space before obtu- engine-driven spiral (Fig. 7.21). Currently, several endodon-
ration. The rationale for drying the canal before obturation is tic sealers are provided with an injection tip to facilitate direct
that sealers tend to be hydrophobic,54 preventing the flow of application of the sealer in the root canal space.
the sealer into the intricacies of the canal space. Moisture can 4. Spreaders are used for lateral condensation of gutta-percha in
also affect the setting property of sealers.54 Like gutta-percha, the root canal space. Spreaders come in different shapes and
paper points are available in different sizes in standardized and sizes (standardized and nonstandardized). They can also be
nonstandardized forms. Another method to dry the canal is finger-held or hand-held (Fig. 7.22).
the use of a surgical suction with a cannula within the canal to 5. Heat source (e.g., System B) has the primary purpose of warm-
remove moisture before obturation. ing the gutta-percha, allowing it to flow under pressure. A heat
3. Sealer is a cement applied inside the root canal space to adhere source can also remove gutta-percha at any level within the
the obturation material to the root canal wall. The ideal prop- root canal space.
erties for sealers were defined by Dr. Louis Grossman (Chapter 6. Thermoplasticized gutta-percha dispensers (e.g., Obtura [Obtura
15). Sealers are available in different compositions. Zinc-oxide Spartan, Algonquin, IL, USA] and Calamus [Dentsply Sirona,
eugenol sealers have been traditionally used. However, modern Tulsa, Oklahoma, USA]) are devices that preheat gutta-percha in
sealers can be composed of epoxy resin or bioceramic mate- a chamber, changing its physical properties from a beta phase to
rials (see Fig. 7.20). According to the type of sealer and the an alpha phase, thereby making it softer and easy to pack using
manufacturer, sealers can be supplied as either a powder and endodontic pluggers. The gutta-percha can then be injected in
liquid, which are mixed at the time of use, or in a preprepared the root canal space and compacted. Once the gutta-percha cools
paste form. The obturation materials are classically placed on a within the root canal space, it changes back to its beta phase, which
glass slab before use. This placement allows for ease of visual- is more stable. Some devices, such as Dual Calamus (Dentsply
ization and a surface to mix the sealer (if required), and it can Sirona, Tulsa, Oklahoma, USA) can have both, a heat source and
be used to form custom-made gutta-percha cones (if needed). a thermoplasticized gutta-percha dispenser, in the same device
The placement of the sealer into the canal can be performed by (Fig. 7.23). Additional details are provided in Chapter 15 regard-
coating a gutta-percha cone or paper point and inserting it into ing the various obturation techniques and armamentarium that
the canal, or via rotary displacement of sealer with a lentulo can be used to manage various clinical cases.
1. All of the following are normally included in an examination kit EXCEPT:

a. Mouth mirror
b. Periodontal probe
c. Cotton pliers
d. Periosteal elevator
e. Dental explorer
2. Which of the following is not found in a typical nonsurgical treatment
cassette?
a. DG16 explorer
b. Anesthetic syringe
c. Retro-pluggers
d. Cotton pliers
e. Plastic instrument
3. A CBCT scan is recommended for examining all the following conditions
EXCEPT:
a. Dental caries detection
b. Internal resorption
c. External resorption
d. Traumatic injuries
e. Treatment planning for apical surgery
4. Rubber dam isolation…
a. Provides a clean operation field
D11 handled spreader (left) and a fine finger spreader (right).
b. Improves visualization of the tooth to be treated
Both are designed for lateral condensation.
c. Prevents aspiration of dental instruments
d. Limits the visibility to the floor of the mouth
e. All of the above
5. All of the following irrigants are used for nonsurgical root canal
treatment EXCEPT:
a. NaOCl
b. EDTA
c. formocresol
d. Chlorhexidine
e. Sterile saline
Different types of endodontic sealers. Top: Bioceramic sealer Dual Calamus obturation device. On the left side is the heat
(Brassler, Augusta, GA, USA). Bottom: AH plus sealer (Dentsply Sirona, system; on the right side is a thermoplasticized gutta-percha dispenser.
Tulsa, OK, USA).
materials were eugenol-based, such as zinc oxide eugenol (ZOE)
Coronal Seal or intermediate restorative material (IRM). Noneugenol based
materials, such as Cavit or glass ionomer are more commonly
After completion of RCT, the access opening in the tooth must used today due to their improved mechanical properties.55-58 A
be restored. Although some treatments can allow for the place- plastic instrument is then used to adapt the temporary filling
ment of a permanent restoration at the time of treatment, the material to the access cavity. It should be noted that the success
tooth after root canal treatment is often sealed with a temporary of endodontic treatment is significantly affected by the quality of
material. The pulp chamber is cleaned of all sealer and gutta- the final restoration.59,60 In a systematic review by Gillen et al.,
percha with a solvent. This process is typically performed using researchers showed that the quality of the coronal restoration is
isopropyl alcohol on a cotton pellet or microbrush. Once com- as important as the quality of the root canal filling for the suc-
plete, a piece of sterile cotton or sponge is placed in the pulp cess of the endodontic treatment.59 Thus nonsurgical endodontic
chamber. The access is then sealed with a temporary material. treatment is fully completed only with a proper permanent res-
Numerous temporary materials have been used historically. Most toration in place.␣
saline. After drainage, the clinician must decide whether to place a

physical drain. Most swellings of endodontic origin that comprise
one fascial space do not require the placement of a physical drain.
The incision site will heal and close after treatment. However, the
site is still weakened and therefore remains the path of least resis-
tance for future swelling, should it occur. If a physical drain would
appear to be beneficial, a piece of rubber dam cut with a dove-
tail can be inserted into the incision. The dovetail should prevent
dislodgement. A suture can also be placed to stabilize the drain
if needed. For more extensive swellings, a Penrose drain can be
inserted and sutured in place. The steps and techniques of drain
placement will be further covered in Chapter 9.␣
Root End Surgery (Apicoectomy)

Armamentarium
Endodontic treatment is usually initiated by cleaning and sealing
the root canal space through the crown portion of the tooth. In
certain clinical situations or when a previously root canal–treated
tooth fails, cleaning and sealing the root canal space may require
Basic emergency kit for an incision for drainage includes (1) further treatment using a surgical approach in an attempt to
scalpel handle, (2) blade, (3) periosteal elevator, (4) suction tip, (5) needle
address the canals from the apical end (root end side). For that,
holder, (6) irrigating syringe with an 18-gauge needle, and (7) sterile saline.
A rubber dam drain is a frequent addition.
a completely different set of instruments and materials are used
to allow reflection of the soft tissue and bone, removal of the
granulomatous tissue, resection of the apical portion of the root,
preparation, and filling of the root end portion from an apical
Surgical Armamentarium approach. This process can be followed by guided tissue regenera-
tion, if needed, and suturing the soft tissue back to its place. The
Incision and Drainage Armamentarium surgical cassette (Fig. 7.25) consists of (1) scalpel, (2) periosteal
Patients can present with swelling before or after endodontic elevator, (3) retractors, (4) bone curettes, (5) periodontal curettes,
therapy. The swelling can be defined as indurated (cellulitis) or (6) micromirrors, (7) retro pluggers, and (9) needle holders. Also,
fluctuant (abscess). The swelling can be confined to one fascial other instruments and materials are needed in combination with
space or spread to multiple spaces. The practitioner should always the surgical cassette, such as (1) blades, (2) Impact Air handpiece
remember that not all swellings are from dental (endodontic) (see later section), (3) burs, (4) retro-preparation ultrasonic tips,
cause. After the swelling has been definitively determined to be (5) hemostatic agents, (6) dye, (7) retro-filling material, and (8)
of endodontic origin and a thorough review of the patient’s past suture material. The armamentarium used for root end surgery
medical history does not contraindicate patient treatment, inci- has been modified in the past two decades to allow better man-
sion and drainage of the swelling is required. Incision and drain- agement of the soft tissue, bone structure, and root end portion
age for endodontic issues is not a solitary treatment. Endodontic of the tooth. The term used for these instruments in today’s prac-
therapy in addition to incision and drainage is required to remove tice is “microsurgical armamentarium,” and hence the procedure
the source of the infection and speed resolution of the swelling. today is termed “microapical surgery,” rather than just traditional
The armamentarium used for an incision and drainage is relatively “apical surgery.” The success rate of microsurgery is very high, in
basic and includes (1) scalpel, (2) periosteal elevator, (3) hemo- the 90% range,61-64 and has been shown to be superior to tradi-
stat and (4) sterile saline in a plastic syringe, and (5) drain (Fig. tional endodontic surgery.17,65 Thus the use of the appropriate
7.24). Proper anesthesia should be administered before any inci- armamentarium (and filling material) can play a major role in the
sion. A scalpel is used to make an incision in the dependent base success of the treatment provided. The blades used in microsur-
of the swelling. Number 12 and 15 blades are the most commonly gery, such as microblades or #15 C, are smaller and more precise
used blades for this procedure. The type of blade used, however, to cut soft tissue, compared with traditional surgery that often
may vary depending on the location and accessibility of the most involved a #15 blade (Fig. 7.26). If microblades are to be used, a
fluctuant part of the swelling. The incision should not simply cut microscalpel will be needed. Using the appropriate blade together
the gingiva but extend to the cortical bone. Whether the incision with proper flap design will result in less recession of the soft tis-
should be vertical or horizontal in origin is debatable. Classically, sue after treatment. Periosteal elevators or mold curettes are used
the incision is made in a horizontal direction. Care should be exer- to reflect the soft tissue away from the bone. They usually come
cised to avoid important anatomic landmarks (e.g., the mental in different shapes and sizes (Fig. 7.27). Selection of the appropri-
foramen) where transient or permanent injury to the underlying ate size will prevent laceration of the soft tissue during reflection.
tissues can occur. After making the incision, a periosteal eleva- Unlike nonsurgical treatment, the Impact Air surgical handpiece
tor is then placed in the incision to perform blunt dissection. If is designed with a 45-degree angled head to allow for better vis-
the swelling is fluctuant, this procedure should provide laudable ibility while cutting the bone (Fig. 7.28). It also does not release
pus and exudate drainage. In some cases, a curved hemostat may any air into the surgical site to avoid the possibility of surgical
be needed to drain and decompress the swelling. The hemostat is emphysema. The flap is retracted using the appropriate retractor.
inserted and bluntly forced into the swelling to lyse any locula- A classical retractor often used is the Minnesota retractor. Other
tions. The incision should then be copiously irrigated with sterile retractors have been developed to facilitate easier retraction in the
Surgical cassette for root end surgery.
Different types of blades, from top to bottom: (1) standard 15

blade, (2) 15 C blade, and (3) microblade.
anterior and posterior area (Fig. 7.29). Surgical burs are used to Mold curettes used to reflect the flap off the bone and elevate
the periosteum.
remove bone, create the osteotomy, and cut the root end por-
tion of the tooth. After the osteotomy, bone curettes are needed
to remove the granulation tissue from the bony crypt. They also
come in different sizes to accommodate for the size of the bony
crypt (Fig. 7.30). The granulation tissue is often attached to the
root; thus periodontal curettes are used to release the granula-
tion tissue from the root surface (Fig. 7.31). Retro preparation
is then initiated using specially designed ultrasonic tips (retro-
preparation tips), which come in different angulations and sizes
to accommodate the different roots (anterior or posterior) (Fig.
7.32). They are also available in different lengths (3 mm, 6 mm,
and 9 mm). Although 3 mm retro preparation tips are the most
commonly used, 6 mm and 9 mm tips can be often used to allow
further cleaning of the root canal space from an apical direction in
special clinical cases. Micromirrors are used to visualize the root
end portion of the tooth after retro preparation to ensure that no
cracks are present (Fig. 7.33). This technique can be combined Surgical handpiece with a 45-degree angled head (left). Non-
with the use of dyes to stain the apical end of the root as well surgical handpiece for standard dental work.
categories of retro-filling materials have been used in endodontic

surgery. Traditionally, amalgam has been used as a retro-filling
material. Due to its moisture sensitivity, it did not provide an
adequate seal in the apical area,67,68 and as a result, the outcome
of apical surgery was affected.17 Over the years, several other
retro-filling materials have been introduced, such as IRM, glass
ionomer, and resin-based retro-filling material. The most recently
introduced and commonly used material in today’s microsurgery
armamentarium are calcium silicate–based materials such as min-
eral trioxide aggregate (MTA; Dentsply Sirona, Tulsa, Oklahoma,
USA) or Bioceramic putty (Brassler, Augusta, Georgia, USA).
These materials have shown superiority in their sealing ability as
well as stimulation of hard tissue repair.68,69 Depending on the
crypt size and bone structure, bone substitutes and resorbable
Surgical retractors with different tip design for retraction at vari- membranes can be placed into the bony crypt to enhance and/
ous locations.
or restore the integrity of the supporting structure.70,71 Finally,
sutures are used to place the flap back in position. Sutures also
as transillumination to visualize any apical defects66 (Fig. 7.34). come in different sizes, starting 1-0 to 10-0. Usually, 5-0 or 6-0
Adequate bleeding control is required for proper visualization and sutures are used to approximate the flap back to its place. For that
placement of the root end filling. For that, hemostatic agents such process, specially designed needle holders would be used to allow
as epinephrine pellets, ferric sulfate, or resorbable collagen can be adequate manipulation of the small threads (Fig. 7.35). More
used to control bleeding. The retro-filling material is then placed, details regarding the use of all these instruments are discussed in
using carriers or hand instruments, into the retro cavity. Different Chapter 21.
6. Endodontic surgery “apicoectomy” includes: 9. Surgical operating microscopes are superior to dental loops in
a. Resection of an entire root a. Provides higher magnification
b. The placement of a retro-filling material to seal the root canal b. Allowing minimal illumination
apically c. Minimizing neck strains
c. The use of NaOCl to disinfect the osteotomy site d. All of the above
d. Stimulation of bleeding to improve visualization and placement of a e. Only a and c
retro-filling material 10. All of the following can be utilized to locate the canal orifices EXCEPT:
7. Dental operating microscopes are beneficial for: a. DG16 explorer
a. The prevention of carpal tunnel syndrome in the operator b. Mirror
b. Decreased illumination of the surgical field c. Dental operating microscope
c. Location and negotiation of root canals d. Apex locator
d. Low level magnification e. Caries detection dye
e. Nonsurgical treatment only 11. Which of the following irrigants has the ability to dissolve pulp tissue
8. Which of the following radiographic methods is not commonly used in and disinfect the root canal system?
endodontic diagnosis? a. NaOCl
a. Periapical radiographs b. Ca(OH)2
b. Bitewings c. EDTA
c. CBCT d. Chlorhexidine
d. Panoramic x-ray e. Formocresol
ANSWERS
Answer Box 7 6 b. The placement of a retro-filling material to seal the root
1 d. Periosteal elevator canal apically
2 c. Retro pluggers 7 c. Location and negotiation of root canals
3 a. Dental caries detection 8 d. Panoramic x-ray
4 e. All of the above 9 e. Only A & C
5 c. formocresol 10 d. Apex locator
Angulated bone curettes to facilitate removal of granulation tissue from the periapical lesion.
Periodontal curette to scale the root surface after apical resection and removal of granulation tissue.
Ultrasonic set showing the different ultrasonic tip designs that can be used for root end prepa-
ration in the anterior and posterior roots.
A B
Micromirrors used during endodontic surgery (right). Illustration of the use of a micromirror to
visualize an apical crack (left).
The product called “To Dye For,” used to stain the root surface (left). Illustration of the staining
process in root end surgery (top and bottom right).
13. Khalighinejad N, Aminoshariae A, Kulild JC, et al.: The effect of

the dental operating microscope on the outcome of nonsurgical
root canal treatment: a retrospective case-control study, J Endod
43(5):728–732, 2017.
14. Azim AA, Deutsch AS, Solomon CS: Prevalence of middle mesial
canals in mandibular molars after guided troughing under high mag-
nification: an in vivo investigation, J Endod 41(2):164–168, 2015.
15. Stropko JJ: Canal morphology of maxillary molars: clinical observa-
tions of canal configurations, J Endod 25(6):446–450, 1999.
16. Setzer FC, Kohli MR, Shah SB, et al.: Outcome of endodontic sur-
gery: a meta-analysis of the literature—Part 2: Comparison of end-
odontic microsurgical techniques with and without the use of higher
magnification, J Endod 38(1):1–10, 2012.
17. Tsesis I, Rosen E, Taschieri S, et al.: Outcomes of surgical endodon-
tic treatment performed by a modern technique: an updated meta-
analysis of the literature, J Endod 39(3):332–339, 2013.
18. Sunada: New method for measuring the length of the root canal, J
Dent Res 41(2):1, 1962.
19. Savani GM, Sabbah W, Sedgley CM, Whitten B: Current trends
in endodontic treatment by general dental practitioners: report of a
United States national survey, J Endod 40(5):618–624, 2014.
20. Piasecki L, Carneiro E, da Silva Neto UX, et al.: The use of micro-
computed tomography to determine the accuracy of 2 electronic
apex locators and anatomic variations affecting their precision, J
Endod 42(8):1263–1267, 2016.
21. Martins JN, Marques D, Mata A, Carames J: Clinical efficacy of
electronic apex locators: systematic review, J Endod 40(6):759–777,
2014.
Standard needle holder (left) and Castroviejo needle holder 22. Azim AA, Griggs JA, Huang GT: The Tennessee study: factors
(right). affecting treatment outcome and healing time following nonsurgical
root canal treatment, Int Endod J 49(1):6–16, 2016.
23. Ng YL, Mann V, Gulabivala K: A prospective study of the factors
References affecting outcomes of nonsurgical root canal treatment: Part 1: peri-
apical health, Int Endod J 44(7):583–609, 2011.
1. Schilder H: Filling root canals in three dimensions, Dent Clin North 24. Stokes AN, Tidmarsh BG: A comparison of diamond and tung-
Am 723–744, 1967. sten carbide burs for preparing endodontic access cavities through
2. Schilder H: Cleaning and shaping the root canal, Dent Clin North crowns, J Endod 14(11):550–553, 1988.
Am 18(2):269–296, 1974. 25. Leeb J: Canal orifice enlargement as related to biomechanical prepa-
3. Setzer FC, Hinckley N, Kohli MR, Karabucak B: A survey of cone- ration, J Endod 9(11):463–470, 1983.
beam computed tomographic use among endodontic practitioners 26. Baumgartner JC, Cuenin PR: Efficacy of several concentrations of
in the United States, J Endod 43(5):699–704, 2017. sodium hypochlorite for root canal irrigation, J Endod 18(12):605–
4. Mota de Almeida FJ, Knutsson K, Flygare L: The impact of cone 612, 1992.
beam computed tomography on the choice of endodontic diagnosis, 27. Gordon TM, Damato D, Christner P: Solvent effect of various dilu-
Int Endod J 48(6):564–572, 2015. tions of sodium hypochlorite on vital and necrotic tissue, J Endod
5. Tsai P, Torabinejad M, Rice D, Azevedo B: Accuracy of cone-beam 7(10):466–469, 1981.
computed tomography and periapical radiography in detecting 28. Rosenfeld EF, James GA, Burch BS: Vital pulp tissue response to
small periapical lesions, J Endod 38(7):965–970, 2012. sodium hypochlorite, J Endod 4(5):140–146, 1978.
6. Patel K, Mannocci F, Patel S: The assessment and management of 29. Siqueira Jr JF: Rocas IN, Favieri A, Lima KC: Chemomechanical
external cervical resorption with periapical radiographs and cone- reduction of the bacterial population in the root canal after instru-
beam computed tomography: a clinical study, J Endod 42(10):1435– mentation and irrigation with 1%, 2.5%, and 5.25% sodium hypo-
1440, 2016. chlorite, J Endod 26(6):331–334, 2000.
7. Rodriguez G, Abella F, Duran-Sindreu F, Patel S, Roig M: Influence 30. Zou L, Shen Y, Li W, Haapasalo M: Penetration of sodium hypo-
of cone-beam computed tomography in clinical decision making chlorite into dentin, J Endod 36(5):793–796, 2010.
among specialists, J Endod 43(2):194–199, 2017. 31. Jeansonne MJ, White RR: A comparison of 2.0% chlorhexidine glu-
8. Edlund M, Nair MK, Nair UP: Detection of vertical root fractures conate and 5.25% sodium hypochlorite as antimicrobial endodontic
by using cone-beam computed tomography: a clinical study, J Endod irrigants, J Endod 20(6):276–278, 1994.
37(6):768–772, 2011. 32. Khademi A, Usefian E, Feizianfard M: Tissue dissolving ability of
9. Bender IB, Seltzer S: Roentgenographic and direct observation of several endodontic irrigants on bovine pulp tissue, Iran Endod J
experimental lesions in bone: I. 1961, J Endod 29(11):702–706, 2(2):65–68, 2007.
2003; discussion 701. 33. Naenni N, Thoma K, Zehnder M: Soft tissue dissolution capac-
10. Bender IB, Seltzer S: Roentgenographic and direct observation of ity of currently used and potential endodontic irrigants, J Endod
experimental lesions in bone: II. 1961, J Endod 29(11):707–712, 30(11):785–787, 2004.
2003; discussion 701. 34. Ohara P, Torabinejad M, Kettering JD: Antibacterial effects of vari-
11. AAE and AAOMR Joint Position Statement: Use of cone beam ous endodontic irrigants on selected anaerobic bacteria, Endod Dent
computed tomography in endodontics 2015 update, J Endod Traumatol 9(3):95–100, 1993.
41(9):1393–1396, 2015. 35. Okino LA, Siqueira EL, Santos M, et al.: Dissolution of pulp tissue
12. Kersten DD, Mines P, Sweet M: Use of the microscope in endodon- by aqueous solution of chlorhexidine digluconate and chlorhexidine
tics: results of a questionnaire, J Endod 34(7):804–807, 2008. digluconate gel, Int Endod J 37(1):38–41, 2004.
36. Yamada RS, Armas A, Goldman M, Lin PS: A scanning electron 56. Kazemi RB, Safavi KE, Spangberg LS: Assessment of marginal sta-
microscopic comparison of a high volume final flush with several bility and permeability of an interim restorative endodontic mate-
irrigating solutions: part 3, J Endod 9(4):137–142, 1983. rial, Oral Surg Oral Med Oral Pathol 78(6):788–796, 1994.
37. Bystrom A, Sundqvist G: The antibacterial action of sodium hypo- 57. Webber RT, del Rio CE, Brady JM, Segall RO: Sealing quality
chlorite and EDTA in 60 cases of endodontic therapy, Int Endod J of a temporary filling material, Oral Surg Oral Med Oral Pathol
18(1):35–40, 1985. 46(1):123–130, 1978.
38. Nygaard-Ostby B. Chelation in root canal therapy: ethylenediami- 58. Bobotis HG, Anderson RW, Pashley DH, Pantera Jr EA: A micro-
netetraacetic acid for cleansing and widening of root canals. Odontol leakage study of temporary restorative materials used in endodon-
Tidskr 65:3–11, 1957. tics, J Endod 15(12):569–572, 1989.
39. Baker NA, Eleazer PD, Averbach RE, Seltzer S: Scanning electron 59. Gillen BM, Looney SW, Gu LS, et al.: Impact of the quality of coro-
microscopic study of the efficacy of various irrigating solutions, J nal restoration versus the quality of root canal fillings on success of
Endod 1(4):127–135, 1975. root canal treatment: a systematic review and meta-analysis, J Endod
40. Basrani BR, Manek S, Sodhi RN, et al.: Interaction between sodium 37(7):895–902, 2011.
hypochlorite and chlorhexidine gluconate, J Endod 33(8):966–969, 2007. 60. Ray HA, Trope M: Periapical status of endodontically treated teeth
41. Bui TB, Baumgartner JC, Mitchell JC: Evaluation of the interaction in relation to the technical quality of the root filling and the coronal
between sodium hypochlorite and chlorhexidine gluconate and its restoration, Int Endod J 28(1):12–18, 1995.
effect on root dentin, J Endod 34(2):181–185, 2008. 61. Rubinstein RA, Kim S: Long-term follow-up of cases considered
42. Baumgartner JC, Mader CL: A scanning electron microscopic evaluation healed one year after apical microsurgery, J Endod 28(5):378–383,
of four root canal irrigation regimens, J Endod 13(4):147–157, 1987. 2002.
43. Chow TW: Mechanical effectiveness of root canal irrigation, J Endod 62. Shinbori N, Grama AM, Patel Y, et al.: Clinical outcome of end-
9(11):475–479, 1983. odontic microsurgery that uses EndoSequence BC root repair
44. Psimma Z, Boutsioukis C, Kastrinakis E, Vasiliadis L: Effect of nee- material as the root-end filling material, J Endod 41(5):607–612,
dle insertion depth and root canal curvature on irrigant extrusion 2015.
ex vivo, J Endod 39(4):521–524, 2013. 63. Kim S, Song M, Shin SJ, Kim E: A randomized controlled study of
45. Boutsioukis C, Lambrianidis T, Verhaagen B, et al.: The effect of mineral trioxide aggregate and super ethoxybenzoic acid as root-end
needle-insertion depth on the irrigant flow in the root canal: evalu- filling materials in endodontic microsurgery: long-term outcomes,
ation using an unsteady computational fluid dynamics model, J J Endod 42(7):997–1002, 2016.
Endod 36(10):1664–1668, 2010. 64. Chong BS, Pitt Ford TR, Hudson MB: A prospective clinical study
46. Gao Y, Haapasalo M, Shen Y, et al.: Development and validation of mineral trioxide aggregate and IRM when used as root-end fill-
of a three-dimensional computational fluid dynamics model of root ing materials in endodontic surgery, Int Endod J 36(8):520–526,
canal irrigation, J Endod 35(9):1282–1287, 2009. 2003.
47. Boutsioukis C, Verhaagen B, Versluis M, et al.: Evaluation of irrigant 65. Setzer FC, Shah SB, Kohli MR, et al.: Outcome of endodontic sur-
flow in the root canal using different needle types by an unsteady gery: a meta-analysis of the literature—part 1: comparison of tra-
computational fluid dynamics model, J Endod 36(5):875–879, 2010. ditional root-end surgery and endodontic microsurgery, J Endod
48. Caron G, Nham K, Bronnec F, Machtou P: Effectiveness of dif- 36(11):1757–1765, 2010.
ferent final irrigant activation protocols on smear layer removal in 66. Tawil PZ, Saraiya VM, Galicia JC, Duggan DJ: Periapical micro-
curved canals, J Endod 36(8):1361–1366, 2010. surgery: the effect of root dentinal defects on short- and long-term
49. Desai P, Himel V: Comparative safety of various intracanal irriga- outcome, J Endod 41(1):22–27, 2015.
tion systems, J Endod 35(4):545–549, 2009. 67. Torabinejad M, Lee SJ, Hong CU: Apical marginal adaptation of
50. van der Sluis LW, Versluis M, Wu MK, Wesselink PR: Passive ultra- orthograde and retrograde root end fillings: a dye leakage and scan-
sonic irrigation of the root canal: a review of the literature, Int Endod ning electron microscopic study, J Endod 20(8):402–407, 1994.
J 40(6):415–426, 2007. 68. Torabinejad M, Higa RK, McKendry DJ, Pitt Ford TR: Dye leakage
51. Hasselgren G, Olsson B, Cvek M: Effects of calcium hydroxide and of four root end filling materials: effects of blood contamination,
sodium hypochlorite on the dissolution of necrotic porcine muscle J Endod 20(4):159–163, 1994.
tissue, J Endod 14(3):125–127, 1988. 69. Baek SH, Plenk Jr H, Kim S: Periapical tissue responses and cemen-
52. Law A, Messer H: An evidence-based analysis of the antibacterial effec- tum regeneration with amalgam, SuperEBA, and MTA as root-end
tiveness of intracanal medicaments, J Endod 30(10):689–694, 2004. filling materials, J Endod 31(6):444–449, 2005.
53. Jasper E: Root canal therapy in modern dentistry, Dental Cosmos 70. Taschieri S, Corbella S, Tsesis I, et al.: Effect of guided tissue regener-
75:823–829, 1933. ation on the outcome of surgical endodontic treatment of through-
54. Whitworth J: Sealer selection: a considered approach, Endod Prac and-through lesions: a retrospective study at 4-year follow-up, Oral
2(3):31–38, 1999. Maxillofac Surg 15(3):153–159, 2011.
55. Anderson RW, Powell BJ, Pashley DH: Microleakage of temporary 71. Tsesis I, Rosen E, Tamse A, et al.: Effect of guided tissue regenera-
restorations in complex endodontic access preparations, J Endod tion on the outcome of surgical endodontic treatment: a systematic
15(11):526–529, 1989. review and meta-analysis, J Endod 37(8):1039–1045, 2011.
12
Root Canal Anatomy
MARCO VERSIANI, BLAINE CLEGHORN, AND
WILLIAM CHRISTIE
CHAPTER OUTLINE
Introduction, 225 Root Canal Anatomy of Maxillary and Mandibular Teeth, 242
Root Canal Components and Morphology, 229 Influence of Root Canal Anatomy in Endodontic Procedures, 254
Root Canal Configuration Systems, 235 Clinical Outcome Remarks, 257
Root Canal Anomalies and Embryologic Malformations, 235 Conclusions, 258
LEARNING OBJECTIVES
After reading this chapter, the student should be able to: 11. Draw a representative example of the most common internal
1. Recognize errors that may cause difficulties or failures in root and external anatomy of each tooth in the following planes: (1)
canal treatment owing to lack of knowledge of pulp anatomy. sagittal section of mesiodistal and faciolingual planes and (2)
2. List techniques that help determine the type of root canal sys- cross-section through the cervical, middle, and apical thirds.
tem. 12. Suggest methods for determining whether roots and canals
3. Draw the eight most common canal types (Vertucci’s I to VIII), are curved and the severity of the curvature.
the shapes of roots in cross-section, and common canal con- 13. Explain why many root curvatures are not apparent on stan-
figurations in these roots. dard radiographs.
4. Understand the two most commonly used classification sys- 14. State the tenet of the relationship of pulp-root anatomy.
tems (Vertucci and Weine) for root canal system and their limi- 15. List each tooth and the root or roots that require a search for
tations. more than one canal.
5. Describe a new classification system of root canal system mor- 16. List and recognize the significance of iatrogenic or pathologic
phology that uses universal tooth number along with canal factors that may cause alterations in root canal anatomy.
number and morphology of individual roots as depicted in 17. Define the root canal space and list and describe its major com-
cleared bench specimens or clinical tomography images. ponents.
6. Know about root canal research in the past and understand 18. Describe variations in the root canal system in the apical third.
how present research is helping identify the complexity and 19. Describe how to determine clinically the distance from the
variations in ethnicity of the human root canal system. occlusal-incisal surface to the roof of the chamber.
7. Describe the most common root and root canal anatomy of 20. Discuss the location, morphology, frequency, and importance
each tooth. of accessory (lateral) canals.
8. For each tooth type, list the average length, number of roots, 21. Describe relationships between the anatomic apex, radio-
and most common root curvature directions. graphic apex, and actual location of the apical foramen.
9. Characterize the most frequent variations in root and root 22. Describe common variations in root canal anatomy resulting
canal anatomy of each tooth group. from developmental abnormalities and state their significance.
10. Explain why standard periapical radiographs do not present 23. Identify the most common root and root canal morphologic
the complete picture of root and root canal anatomy. variations as they relate to ethnicity.
Introduction byproducts are removed from the canal space. However, this
objective may be difficult to attain in reality because of the com-
The ultimate goal of endodontic therapy is to seal the root canal plexity of the internal anatomy of teeth. Residual bacteria and
system after all vital or necrotic tissue, microorganisms, and their debris may remain relatively unaffected in the missed canal system
225
226 C HA P T E R 1 2 Root Canal Anatomy
or even in the unprepared canal walls, isthmuses, lateral canals, Methods of Study to Learn Normal and
apical ramifications, and recesses from oval/flattened canals which Variations in Tooth Anatomy
may compromise the successful treatment outcome. Thus, a thor-
ough understanding of the number of canals, of the inner-canal In the first half of the 16th century, a set of seven books written
morphology, and the variations in all groups of teeth is a basic by Andreas Vesalius (1514-1564) entitled De Humani Corporis
requirement for successful endodontic therapy. Fabrica was published. This was a major advance in the history of
In the past, several studies were performed on the range of vari- anatomy over the long-dominant works of ancient Middle Ages
ations in human root canal anatomy, and the findings have had a writers. It is noteworthy that an important anatomic aspect of
noteworthy influence on clinical practice. In recent years, significant teeth that had been ignored by previous authors on which, centu-
noninvasive technological advances for imaging teeth have been intro- ries later, the endodontic specialty would be born, was highlighted
duced that allow anatomic studies to be done using large populations for the first time in the literature. In Chapter XI, there is a drawing
and evaluate specific and fine anatomic features of a tooth group. The of a sectioned two-rooted mandibular molar showing its internal
latest morphological studies on root and root canal anatomy use high- anatomy (Fig. 12.1, A ). In 1563, Bartolomeo Eustachi (c. 1520-
resolution three-dimensional (3D) tomographic images to illustrate 1574), in his treatise il Libellus de Dentibus, made very significant
and define terminologies associated with this topic. contributions toward the anatomy and physiology of the dentition,
including the first descriptions of the dental pulp, the periodon-
Gaining Knowledge and Comprehension of Root tal ligament, the dental follicles, the trigeminal nerve, and other
oral structures, based upon extensive dissections of both human
and Canal Anatomy and animal specimens. In Chapter XVIII, Eustachi describes the
Textbooks and courses in dental anatomy are ideal sources for pulp cavity and its contents, and shows accurate tables in which
teaching a dental student about normal human tooth anatomy. he specified the number of roots and the external morphologic
These study aids can present the dental student or dental prac- variations of all groups of human teeth (Fig. 12.1, B). Eustachi’s
titioner with knowledge of the ideal coronal anatomy and its book brought the macroscopic anatomy of teeth to a high degree
relation to occlusion, the anatomy of the human tooth root, and of perfection that remained unsurpassed until the 19th century
occasionally the morphology of the pulp and root canals. But the with the posthumous work of Georg Carabelli (1787-1842), who
usual dental anatomy that is shown assumes the ideal (or most fre- provided the most detailed description of the number and direc-
quently encountered) tooth shape. Is this enough to perform end- tion of the root canals at that time (Fig. 12.1, C). Nevertheless, it
odontic treatment for our patients, when genetic variations may was only at the end of 19th century that some researchers finally
have produced roots and root canal systems that vary from the realized the need for in-depth research on root canal morphology.
normal? For example, why is the maxillary first premolar inevita- In 1903, Gustav Preiswerk (1866-1908) performed a profound
bly depicted as having two roots (and two canals) whereas the sec- and comprehensive study on this subject. In his pioneering study,
ond premolar is illustrated as a single but oval rooted tooth with Wood’s metal, an alloy that melts at a low temperature, was mol-
one, or maybe two canals? Studies that compare the incidence of ten and injected into the canal space. After complete decalcifica-
variation in root number in different populations have shown a tion of the teeth, 3D metal models of the internal anatomy were
significant variation in morphology of the human maxillary and obtained for the first time (Fig. 12.1, D). Some years later, Guido
mandibular premolars, based on ethnicity.1 Therefore, when it Fischer (1877-1959) presented the challenging nature of the api-
comes to performing the complex operation of root canal therapy, cal root anatomy. He obtained better results than Preiswerk by
more detailed knowledge of root number and root canal system filling approximately 700 teeth with a collodion solution. This
anatomy is required. The purpose of this chapter is to acquire that solution penetrated all the branches of the root canal system and
knowledge at a higher level. hardened in 2 or 3 weeks, providing a full 3D replica of the root
The first task for a dental student, as stated, is to learn the canal system (Fig. 12.1, E). The complexity and unpredictability
normal anatomy of each tooth in the arch with respect to its of the root canal morphology led Fischer to coin the term Kanal-
complex root canal system. In principle, the shape of the exter- system, which has been widely used nowadays as “root canal sys-
nal root will be reflected in the internal morphology of a root tem.” It may be said that the innovative 3D anatomic studies of
canal system. This is considered a tenet of the relationship of Preiswerk and Fischer resulted in huge advancements, adding new
pulp-root anatomy. Each of the individual 16 types of teeth in and significant knowledge to the dental literature and stimulating
the permanent dentition has its own individual root canal system other researchers to undertake further investigations on this topic.
morphology or shape. This is considered basic dental anatomy, In those later studies, large numbers of extracted teeth were col-
which must then be matched clinically to what is interpreted lected, placed in a category and analyzed, or counted to compare
from the two-dimensional (2D) shadow of the radiographic their shape and size. Root numbers for the multirooted posterior
image. teeth could even be tabulated. Data from these in vitro studies
The second task is to acquire detailed dental anatomy knowl- were then printed in the tables found in the earliest textbooks
edge of possible variations from the norm. Thus one should in dentistry. This was the first phase of research in human root
realize that each human tooth type has a range of variation in anatomy.2
its morphology. The shape of the root canal system is influenced Hess wrote a landmark publication on the morphology of
by embryonic development and is controlled by each patient’s root canals using some 3000 permanent teeth. Canal shapes were
genetic background. To perform successful endodontic treatment, made visible by injecting vulcanite into canal systems and dissolv-
one must anticipate variation in chamber size and depth from the ing the surrounding roots. This process showed graphically how
occlusal surface, the canal size, shape, length, curvature, branches, complex the canal system was for each tooth (Fig. 12.1, F ). A
lateral canals, and apical accessory canals, to mention just a few similar method was used for primary teeth by Zürcher, and the
variables. These variations may or may not be clearly seen in a results were combined and reprinted in the English literature
standard periapical radiographic image.␣ in 1925. Many variable shapes and extra canals in single rooted
CHAPTER 12 Root Canal Anatomy 227
teeth were shown to exist. For example, in the casts of mandibular

incisor, mandibular premolar, and mandibular canine, the canals
were complex and sometimes multiple in number. Illustrations in
his publication are remarkable for their accuracy but were either
overlooked or ignored as being abnormal variants at the time.
Subsequent anatomic studies and an earlier published study have
confirmed their observations.2 More recent studies on canal num-
bers, both ex vivo and in vivo, have shown that former endodontic
A techniques in root canal therapy using less flexible instruments
only available at the time had inadvertently missed many of these
extra and complex canal systems.3
Clinical competence relies on the development of the widely
recognized psychomotor aspect. Inextricably coupled with these
psychomotor skills is the ability to self-evaluate the process of cor-
B rection and the product itself compared with the desired outcome.
Visual perception has been suggested as a prerequisite skill for
determining the appropriate goals and strategy for a correction.
Visual skill is required to observe normal 3D tooth morphology
in detail, to differentiate normal tooth morphology from its varia-
tions. Further, motor skills are also required to execute clinically
relevant dental procedures. In the development of psychomotor
skills, the student must teach his or her hands to do that which
C his or her mind dictates as correct. Models that simulate teeth
in which root canals can be visualized would serve as valuable
teaching aids in offering direct visual information on the effects of
instrumentation during endodontic procedures. The visual expe-
riences afforded by these models must provide mental images,
which can be transferred to the performance of endodontic proce-
dures on actual teeth. Nowadays, most dental schools continue to
present foundational knowledge of dental anatomy in lectures and
to develop students’ psychomotor skills through a combination
D of 2D drawing projects, radiographs, and exercises to carve teeth
from oversized wax blocks. As a result, neither knowledge nor psy-
chomotor skills are learned in the context of clinical practice, thus
potentially hindering the student’s ability to later recall and apply
learning to actual patient care. On the other hand, practice on
E extracted teeth has been a universal method of teaching preclinical
endodontics and gives students the opportunity of gaining exper-
tise before moving to treating patients. However, infection con-
trol concerns, originated by the manipulation of extracted teeth,
along with ethical factors are threatening such preclinical labora-
tory practice in some teaching institutions. These drawbacks have
stimulated the development of alternative simulation methods for
A B C D E F
teaching root canal anatomy.4␣
Root Canal Anatomy Since the Age of

Specialization in Endodontics
One must not take away from dental practitioners who revived
A B C D E F the popularity and viability of root canal therapy after the mis-
F informed attitudes in the age of “Focal Infection Theory.” By the
Historical images of classical studies on root canal anat- mid-20th century the attitudes and instruments in endodontics
omy. A, First drawing of a sectioned two-rooted mandibular molar show- had changed;5 thus standardization of instruments and techniques
ing its internal anatomy by Andreas Vesalius (1543); B, illustration depicting led to saving many more teeth, while using a recognized and effec-
the number of roots and the external morphologic variations of all groups tive treatment rationale. However, it was recognized that if missed
of human teeth by Eustachi (1563); C, illustration of the number and direc-
canals were leading to failure to seal the entire canal system, then
tion of the root canal in different groups of teeth by Carabelli (1842); D,
3D metal models of the internal anatomy of different teeth obtained by
new studies on the variability of root and canal anatomy had to be
Preiswerk (1903); E, 3D models of the internal anatomy of teeth obtained done. New methods of study were devised that used both radio-
by Fischer using collodion solution (1907); F, Canal shapes of mandibu- graphs and bench studies of extracted teeth. This has led to the
lar molars obtained by injecting vulcanite into the canal systems by Hess second phase of research in dental and root anatomy, which began
(1925). (Courtesy Dr. Perrini.241 Published with permission.) about the time of recognition of endodontics as a specialty branch
of restorative dentistry in 1964 in the United States.
These tooth anatomy studies included methods such as con- rapid prototyping printer, allowing the students to hold them in
ventional and laboratory radiography (with or without contrast hand to observe details of the internal anatomy in different views.
media), resin injection, macroscopic and microscopic evaluations, Additional applications of printed models in dental education also
tooth sectioning, root clearing techniques, and scanning electron include the possibility to (1) scale the teeth for didactic purposes,
microscopy. Kuttler in 19556 used a dissection microscope to show (2) build a collection of 3D tooth models showing atypical or
that the apical foramen in teeth varied considerably in diameter. only regionally prevalent anatomies, (3) produce a large number
Skidmore and Bjørndal in 19717 illustrated casts of mandibular of teeth for destructive analysis, (4) present the teeth in the form
first molars with multiple and complex canal systems. Another of individual substructures that need to be assembled correctly by
example of the practical aspect of studying root morphology was the students, and (5) build an extensive collection of 3D models
the paper by Davis et al. in 19728 that described the use of injected of healthy and diseased teeth using raw data made available online
silicone into standard endodontic-prepared canals, with the result- by researchers and dentists from all over the world.4
ing casts showing that some areas of the canal system had not been As imaging has been adopted in modern dental education,
completely shaped. All of these canal anatomy studies and more, it has benefited from the concurrent development of technolo-
either in physical anthropology papers or in dental journals, built gies that have allowed the material to be presented electronically.
on a second wave of root and canal system knowledge.9-11 One of the technologies with the greatest effect has been the
Undoubtedly, these techniques have shown a great potential for Internet. The Internet has increasingly been used as an educa-
endodontic research. However, although most of these methods tional tool as a result of its ability to provide a large volume of
required the partial or even full destruction of the studied samples educational material in a single, readily accessible location and
rendering irreversible changes in the specimens and many arti- permitting flexibility in the material format.4 Images, text, inter-
facts, others provided only a 2D image of a 3D structure.12 These active quizzes, and videos can be integrated seamlessly into a
inherent limitations have repeatedly been discussed, encouraging comprehensive educational resource. In this way, digital images
the search for new methods with improved possibilities. acquired from micro-CT devices could be used to generate ana-
More recently, the third phase of studies in human root and tomic tooth data on a large scale and made freely accessible to the
root canal anatomy is well underway. Increased computer power of public through the Internet (www.rootcanalanatomy.blogspot.
digital radiographs and advanced technology are producing studies com), thus circumventing the problems of individual researchers
of human teeth with conventional medical computed tomography requiring access to high-cost scanning devices.13 Therefore one
(CT), magnetic resonance microscopy, tuned-aperture CT, opti- of the most important aspects of the computer age of communi-
cal coherence tomography, volumetric or cone beam CT (CBCT; cation is the ability to find and access research from many more
used as a clinical enhancement of practice), and micro–computed dental schools and dental researchers from all over the dental
tomography (micro-CT). CT-based training replicas produced academic world. Although a computer search may seem quick
using 3D printing technology have improved the use of artificial and easy, one must rely only on reliable research publications
teeth for teaching purposes (Fig. 12.2). Replicas with different from journals with a credible and high impact factor. A new
root canal complexities can be printed as oversized models in a understanding has been forthcoming on the importance of eth-
nicity and human dental anatomy.14
The misconception of thinking about “one-root equals one-
canal” in endodontic treatment has been shattered by a number
of classic papers that demonstrate otherwise. In fact, a number
of studies have classified and described the morphology of mul-
tiple canals in a broad diameter root. This multiple canal con-
figuration may divide, combine, and separate as it forms in root
closure toward the various morphologies of the apical foramen
terminus.15 It is prudent to assume that any root that requires
treatment may contain more than one canal system per root, until
proved otherwise.␣
A
Multiple Canals Within a Single Root
Weine et al. in 196916 were the first authors to recognize and pub-
lish how commonly two canals in one root occurred, and then to
classify the two canals in the mesiobuccal root of the maxillary
first molar tooth as the “type specimen” (Fig. 12.3, A). Piñeda and
Kuttler in 197217 used radiographs on 7275 extracted teeth to
demonstrate multiple canal systems in three dimensions not usu-
ally seen in the clinical setting. Other researchers18-20 soon added
observations that confirmed this morphology was not uncommon
in many other broad labiolingual or buccolingual roots, as well as,
B the mesiobuccal root of maxillary molars.
Replicas of various teeth manufactured from corresponding
Vertucci et al.21 developed a more complex classification that
real-tooth micro-CT scans using three-dimensional (3D) printing technol- is better adapted to research and applied in any other tooth that is
ogy in assorted sizes for didactic or teaching purposes. A, True Tooth®; wider in the labiolingual or buccolingual dimension (Fig. 12.3, B).
B, RepliDens®. (A, images available at https://dentalengineeringlab.com/ Essentially, Weine and Vertucci’s configuration systems were based
truetooth/; B, images available at https://www.smartodont.ch/replidens/.) on the number of root canals that begin at the pulp chamber floor,
Weine’s Configuration System arise along the course of the canal, and open through an apical
foramen. Later, Versiani and Ordinola-Zapata22 expanded and
Type I Type II Type III Type IV
adapted these classifications to 3D tomographic descriptions of
(1-1) (2-1) (2-2) (1-2)
at least 37 complex canal systems possible to be observed in a
single root (Fig. 12.4). The following tables of root numbers of
tooth pairings will help one understand the variation in incidence
of single and multiple canal numbers based on a large sample
from multiple studies. The computer-generated figures will also
show graphically some of the variations in anatomy that may be
found in the human dentition. Other research studies have shown
that furcation canals, lateral canals, and apical ramifications have
developed all too commonly.23 Better cleansing and obturation
techniques will more likely seal all portals of exit in the chamber
A and canal and lead to higher success rates in studies, based on
Vertucci’s Configuration System evidence.
Type I Type II Type III Type IV
Success in root canal therapy can be achieved by first knowing
(1-1) (2-1) (1-2-1) (2-2) the normal canal anatomy and then by being aware of the many
variations that the path of the canal system can follow. One should
be able to develop a 3D visualization, both in longitudinal and
in cross-section while still using clinical tactile sense to guide a
file toward the apical foramen or apical terminus. The following
description and images will help provide that knowledge to aid
one in honing that skill and expertise.␣
Root Canal Components and Morphology

Basically, the root canal system can be divided into two parts: the
pulp chamber, commonly located within the anatomic dental
Type V Type VI Type VII Type VIII
(1-2) (2-1-2) (1-2-1-2) (3-3)
crown, and the root canal space, found inside the radicular por-
tion of the tooth.24
Pulp Chamber
The pulp chamber is a cavity normally situated in the center of the
crown and, when there are no pathologic conditions, resembles
the shape of the crown surface. In anterior teeth that have a single
canal in one root, the pulp chamber and root canal are continuous
whereas, in posterior teeth with multiple canals and more than
one root, the pulp chamber floor separates these two components.
B In premolars and molars, the pulp chamber usually presents a
A, Diagrammatic representations of Weine’s classification for square shape with six sides: the floor, the roof, and four axial walls
root canal morphology. Type I: A single canal from pulp chamber to the identified as mesial, distal, buccal, or lingual (palatal). The pulp
apex (1-1 configuration); Type II: Two separate canals leaving the cham- chamber roof usually presents projections or prominences associ-
ber, but merging short of the apex to form a single canal (2-1 configura- ated with cusps, mamelons, or incisal ridges, denominated pulp
tion); Type III: Two distinct canals from pulp chamber to the apex (2-2 horns.22 In teeth with physiologic wear or other irritation, con-
configuration); Type IV: A single canal leaving the chamber and dividing tinuous dentin formation (either physiologic or reactionary) by
into two separate canals at the apex (1-2 configuration). B, Diagrammatic
primary odontoblasts may lead to a decrease in the pulpal space
representations of Vertucci’s classification for root canal morphology.
Type I: A single canal from pulp chamber to the apex (1-1 configuration);
dimensions which, in some cases, can compromise root canal
Type II: Two separate canals leaving the chamber, but merging short of treatment.25
the apex to form a single canal (2-1 configuration); Type III: A single canal Based on the anatomic study of 500 teeth, Krasner and
that divides into two, and subsequently merges to exit as one (1-2-1 Rankow26 demonstrated that specific and consistent pulp cham-
configuration); Type IV: Two distinct canals from pulp chamber to the ber anatomy exists. Then, they proposed some general rules or
apex (2-2 configuration); Type V: A single canal leaving the chamber and laws (Fig. 12.5) for aiding in the determination of the pulp cham-
dividing into two separate canals at the apex (1-2 configuration); Type VI: ber position and the location and number of root canal entrances
Two separate canals leaving the pulp chamber, merging in the body of in each group of teeth:
the root, and dividing again into two distinct canals short from the apex Law of centrality: The floor of the pulp chamber is always located
(2-1-2 configuration); Type VII: A single canal that divides, merges, and
in the center of the tooth at the level of the cementoenamel junc-
exits into two distinct canals short from the apex (1-2-1-2 configuration);
Type VIII: Three distinct canals within one root from pulp chamber to the
tion (CEJ).
apex (3-3 configuration). Law of concentricity: The walls of the pulp chamber are always
concentric to the external surface of the tooth at the level of the
CEJ (i.e., the external root surface anatomy reflects the internal
pulp chamber anatomy).
1 apical foramen 2 apical foramina 3 apical foramina 4 apical foramina
1 1-2-1 1-2-1-2-1 4-1 2 2-3-2 1-2 3 1-3 4
1-2-3-1 1-2-3-2-1 1-3-1 2-3-2-3-2 1-2-1-2 2-3-4-3-2 1-2-3 1-2-1-3 3-4
2-1 2-1-2-1 2-3-1 1-2-3-2 3-1-2 2-1-2 1-2-3-2-3 2-1-3 5-4
3-1 3-2-1 3-2-1-3-1 3-2 2-1-2-1-2 4-2 2-3 3-2-3 1-2-3-4

Thirty-seven most common canal configurations possible to be observed in a single root,
according to Versiani and Ordinola-Zapata.22
Law of the CEJ: The distance from the external surface of the In addition to knowing these laws, the use of better illumina-
clinical crown to the wall of the pulp chamber is the same tion and magnification sometimes associated with specific instru-
throughout the circumference of the tooth at the level of the ments, such as thin ultrasonic tips or special burs, would provide
CEJ. The CEJ is the most consistent, repeatable landmark for the best approach to explore the anatomic variations of the pulp
locating the position of the pulp chamber. chamber in order to locate all canal orifices and avoid missed
Law of symmetry 1: Except for maxillary molars, the orifices of canals.24␣
the canals are equidistant from a line drawn in a mesiodistal
direction, through the pulp chamber floor. Root Canal
Law of symmetry 2: Except for the maxillary molars, the orifices
of the canals lie on a line perpendicular to a line drawn in a The root canal is the portion of the pulp canal space within the root
mesiodistal direction across the center of the floor of the pulp of the tooth limited by the pulp chamber and the foramen that
chamber. follows the external outline of the root (Fig. 12.6). The root canal
Law of color change: The color of the pulp chamber floor is can be subdivided into two components: the main canal, which is
always darker than the walls. mostly cleaned by mechanical means, and lateral components com-
Law of orifice location 1: The orifices of the root canals are posed by isthmuses, accessory canals (furcation, lateral and second-
always located at the junction of the walls and the floor. ary canals), and some recesses of flattened- and oval-shaped canals.24
Law of orifice location 2: The orifices of the root canals are In longitudinal section, canals are usually broader faciolingually
located at the angles in the floor-wall junction. than in the mesiodistal plane. Traditionally, canal shape has been clas-
Law of orifice location 3: The orifices of the root canals are sified as round, oval, long oval, flattened, or irregular (Fig. 12.7).27
located at the terminus of the root developmental fusion lines. Its geometric cross-sectional shape has been also quantitatively
Distal Mesial
Buccal
Mesial
Pulp
Floor Distal
Palatal
Dentinal
Wall
A B
Buccal
Buccal
Distal Mesial Distal Mesial
Palatal
Palatal
C D
Three-dimensional (3D) micro–computed tomography (micro-CT) images of posterior teeth
demonstrating the (A) laws of centrality and concentricity, at the cementoenamel junction (CEJ) in a man-
dibular molar tooth; (B) laws of color change and orifice locations 1, 2, and 3 (arrow: developmental fusion
lines) in a four-rooted maxillary second molar tooth; and (C–D) laws of symmetry 1 (three-rooted maxillary
molar) and 2 (two-rooted maxillary premolar).
described by calculating the mean aspect ratio, defined as the ratio the root level, and the patient’s age. Hsu and Kim31 classified the
of the major to the minor canal diameters. The major diameter is isthmuses configuration into five types:
the distance between the two most distant points of the canal in the
buccolingual direction, whereas the minor diameter is the longest
chord through the root canal that could be drawn in the direction
orthogonal to that of the major diameter. Accordingly, an oval- canals instead of two
shaped canal has an aspect ratio between 1 and 2, a long oval canal -
higher than 2 but lower than 4, and a flattened canal has a value tion
higher than 4.28 It is interesting to point out that, in a same tooth,
canal cross-sections may show different shapes at different levels of two main canals.
the root; however, at the apical third, it is more round or slightly It is noteworthy that experimental studies demonstrated the
oval in shape in comparison with the middle and coronal thirds.12,28 impossibility of obtaining a complete mechanical debridement
Thus, as previously mentioned, the anatomy of the root canal sys- or chemical disinfection of isthmuses with the current technol-
tems is often complex and can vary greatly in number and shape. ogy, mostly because of the presence of hard tissue debris packed
into these areas during the mechanical preparation of the main
Isthmus root canal.32-36 Clinical studies have also shown that unfilled isth-
An isthmus, also called transverse anastomosis, is a narrow, ribbon- muses can be commonly observed after root-end resection in cases
shaped communication between two root canals that may contain referred for apicoectomy treatment.37 These limitations, how-
vital tissue, necrotic pulp, biofilms, or residual filling material.29,30 ever, can be surpassed in nonsurgical treatment by using chemi-
Isthmuses (or isthmi) may present with different configurations cal agents that have the ability to dissolve organic tissue at fins
(Fig. 12.8), and their prevalence is dependent on the type of teeth, and isthmuses level, often associated with ultrasonic activation.33
Root Root Root

Canal
Pulp
Crown Chamber Crown
A B
Crown
Pup Horn
Pulp Chamber Roof
Pulp Chamber
Pulp Chamber Floor
Root
Root Canal
C Apex
Three-dimensional (3D) models of real (A) incisor and (B–C) molar teeth, obtained by micro–
computed tomography (micro-CT) technology, showing the main components of the root canal system.
Long-Oval
Oval-Shaped Flattened
Canal
Canal Canal
Round
Irregular
A B Round C
Two-dimensional (2D) root canal cross-sections of three mandibular canines (A–C) showing that canals are usually broader buccolingually than
in the mesiodistal plane, and may present different shapes at distinct levels of the root.
Two-dimensional (2D) root canal cross-sections of four mesial roots of mandibular molars
showing isthmuses with different sizes and shapes at different levels of the root.
Accessory
Canal
Lateral
Canal
Lateral
Canal
Furcation
Canal
A B C
Three-dimensional (3D) models of (A–B) two maxillary central incisors and (C) a two-rooted
mandibular canine, obtained by micro–computed tomography (micro-CT) technology, showing the lateral
components of the root canal system.
In addition, with the advent of the operatory microscope, it is defined as an accessory canal located at the coronal or middle third
possible to identify and treat most of the isthmus areas with thin of the root (Fig. 12.9, A and B).38 They are formed after a localized
ultrasonic tips, in both surgical and nonsurgical endodontic pro- fragmentation of Hertwig’s epithelial root sheath develops, leaving
cedures, to ensure their debridement and seal.34,35␣ a small gap, or when blood vessels running from the dental sac
through the dental papilla persist as collateral circulation.39 Acces-
Accessory Canals sory canals represent potential pathways through which bacteria
An accessory canal is any branch of the root canal that commu- and/or their byproducts from the necrotic root canal might reach
nicates with the periodontal ligament, whereas a lateral canal is the periodontal ligament and cause disease.39
Apical Apex
Foramen
CDJ
Cementum
Apical
Constriction Dentin
A B
A, Anatomic landmarks at the apex of a cleared single-rooted tooth (CDJ: cementodentinal
junction). B, Three-dimensional (3D) micro–computed tomography (micro-CT) model of a mandibular canine
presenting apical ramification (arrow). (A, Courtesy Dr. Francisco Balandrano. Published with permission.)
De Deus23 studied the frequency, location, and direction of the mean distance between 0.2 to 3.8 mm from the anatomic apex,44
accessory canals in 1140 teeth and showed that 27.4% of the sample despite larger distances have been reported recently.45 The ana-
(n = 330) had accessory canals, especially in the apical area (17%), tomic apex is the tip or the end of the root as determined mor-
followed by the middle (8.8%) and coronal (1.6%) thirds. Similarly, phologically.38 Depending on the type of teeth, the apical foramen
Vertucci40 evaluated 2400 teeth and observed a lower occurrence can coincide with the anatomic apex in a percentage frequency
of canal ramifications in the middle (11.4%) and coronal (6.3%) ranging from 6.7% to 46% of the cases.10,17,40,46 Its diameter has
thirds compared with the apical level (73.5%). Lateral canals are not been described between 0.21 to 0.39 mm.47 The mesial roots of
usually visible in preoperative radiographs, but their presence can mandibular molars, the maxillary premolars, and the mesiobuccal
be suspected when there is a localized thickening of the periodontal roots of maxillary molars present the highest percentage of multi-
ligament or there is a lesion on the lateral surface of the root. Clini- ple apical foramina.47 A previous study on root apices of all groups
cally, it is also relevant that lateral canals cannot be instrumented of permanent teeth showed that the number of foramina on each
most of the time. In this way, their content can only be neutralized root may vary from 1 to 16.44
by means of effective irrigation with a suitable antimicrobial solu- The apical portion of the root canal having the narrowest diam-
tion or with an additional use of intracanal medication.24,25 eter has been called the “apical constriction” (minor foramen).38
Canals connecting the pulp chamber to the periodontal liga- From the apical constriction, the canal widens as it approaches
ment in the furcation region of a multirooted tooth are called the apical foramen. The topography of the apical constriction is
furcation canals (Fig. 12.9, C).38 These canals are derived from not constant12,15 and, when present, is usually located 0.5 to 1.5
entrapment of periodontal vessels during the fusion of the parts mm from the center of the apical foramen.30 The cementoden-
of the diaphragm, which will become the floor of the pulp cham- tinal junction (CDJ) is the point at which the cemental surface
ber. In some cases, furcation canals have been associated with terminates at or near the apex of a tooth and meets dentin.38 At
primary endodontic lesions in the interradicular region of mul- this histologic landmark pulp tissue ends and periodontal tissues
tirooted teeth. Vertucci and Williams observed the presence of begin (Fig. 12.10, A).25
furcation canals in 13% of mandibular first molars,41 and in most Another relevant variation of the root canal at or near the apex
of them the canal extended from the center of the pulpal floor, is an intricate network of ramifications, also called apical ramifica-
whereas in four and two specimens, respectively, the canals arose tion of apical delta, which is defined as a morphology in which the
from the mesial and distal aspects of the floor. Later, Vertucci main canal divides into multiple accessory canals (Fig. 12.10, B).38
and Anthony42 observed the presence of foramina on both the In maxillary teeth, the percentage frequency of apical ramification
pulp chamber floor and the furcation surface in 36% of maxillary ranges from 1% (central incisors) to 15.1% (second premolars),
first molars, 12% of maxillary second molars, 32% of mandibu- whereas in mandibular teeth its frequency varies from 5% (central
lar first molars, and 24% of mandibular second molars. Recently, incisors) to 14% (distal root of first molars).40 In the treatment of
micro-CT studies have also demonstrated the presence of furca- clinical cases, the infection of this tortuous and complex anatomic
tion canals in two-rooted mandibular canines and three-rooted configuration with several portals of exit can be related as an etio-
mandibular premolars.43␣ logic factor of nonsurgical failures.39␣
Apical Canal Canal Curvature and Size

The main root canal ends at the apical foramen (major fora- Knowledge of the root curvature is an important factor in choos-
men), which frequently opens laterally on the root surface, at a ing the appropriate chemomechanical protocol for cleaning and
shaping the root canal system. Before the introduction of nickel- was developed based on a clearing study (followed by dye injected
titanium (NiTi) instruments, several iatrogenic procedures were into the canals) of 200 maxillary second premolars and eight canal
associated with the preparation of curved canals including zips, types were described. Vertucci et al.21 defined the Type VIII root
separated instruments, ledges, and perforations.48 Nowadays, canal system as three separate canals in maxillary premolars from
these iatrogenic complications are no longer a problem, except for the pulp chamber to the apex. However, the study did not specify
instrument separation. Therefore this is one of the factors deter- whether the three canals were within a tooth that contained one,
mining the difficulty of treatment and the likelihood of iatrogenic two, or three roots. Many studies have classified Type VIII canal
errors and shows that preoperative recognition of canal curvature configurations lumping single, double, and triple-rooted teeth
is of utmost importance.22 together.21,40,55,56 Some studies, though, have classified three-rooted
Nearly all root canals are curved in the apical third, particu- maxillary premolars with single canals in each root as Type I canal
larly in a faciolingual direction, which is not evident on standard systems in each root.57,58 It seems logical, however, that a Type VIII
radiography.30 In general, the curvature may vary from gradual canal should only be used in one broad or fused root of a tooth, and
curvature of the entire canal, sharp curvature of the canal near not in the separated roots and apex of the same tooth as may be
the apex, or a gradual curvature of the canal with a straight api- shown on the radiograph.
cal ending. Numerous methods have been proposed to determine In addition, numerous other canal types have been reported by
root canal curvature,49,50 but the Schneider’s method has been the various authors that did not fit into either classification system.59
most widely used. Schneider51 classified single-rooted permanent Recently, based on the study of hundreds of permanent teeth, Ver-
teeth according to the degree of curvature of the root, which was siani and Ordinola-Zapata60 found 37 different canal types using
determined by first drawing a line parallel to the long axis of the micro-CT technology (see Fig. 12.4). Clearly, neither the Weine nor
canal, then, a second line connecting the apical foramen to the the Vertucci classification system can adequately describe these addi-
point in the first line where the canal began to leave the long axis tional complex canal configurations. A simple classification system
of the tooth. The angle formed by these two lines was the angle that can be used to describe all of the possible canal configurations
of curvature and its degree was classified as straight (≤5 degrees), in all teeth has yet to be developed. However, a new canal classifica-
moderate (10 to 20 degrees), or severe (25 to 70 degrees). tion system proposed by Ahmed et al.59 shows promise because the
Another method was introduced by Weine52 that also relies on system can accommodate any type of canal configuration by using
the definition of two straight lines, but it reflects the root canal cur- root name and canal numbers to categorize the canal configuration
vature more accurately than Schneider’s method, especially in the in each root (Fig. 12.11).␣
apical part. A third proposal, geometrically equivalent to Weine’s
method, was introduced by Pruett et al.,53 but its major innovation
was the concurrent measurement of the radius of curvature by the Root Canal Anomalies and Embryologic
superimposition of a circular arc on the curved part of the root Malformations
canal. Therefore, the Schneider angle, when used in combination
with the radius and length of the curve, may provide a more precise Anomalous root and root canal morphology can be found asso-
method for describing the apical geometry of canal curvature. ciated with any tooth with varying degrees and frequency in the
Clinically, different angled views are necessary to determine the human dentition. Dental anomalies are formative defects caused by
presence, direction, and severity of the root canal curvature. Schäfer genetic disturbances during the morphogenesis of teeth.61 Anoma-
et al.54 evaluated radiographically the degree of curvature of 1163 root lies may occur during the developmental stages of the tooth that are
canals from all groups of teeth. The degree of curvature ranged from 0 manifested clinically later in life once the tooth is fully formed.62-64
to 75 degrees and from 0 to 69 degrees in clinical and proximal views, Failure to diagnose teeth with anomalous anatomy may lead to mis-
respectively. The highest degree of curvature was observed in the clini- diagnosis and a treatment plan that could cause permanent irrevers-
cal view of the mesiobuccal canal of maxillary molars and in the mesial ible damage and loss of the tooth.30 In this way, the clinician must
canals of mandibular molars. In several cases, the angles of proximal be aware of the existence of some anatomic anomalies to imple-
curvatures were higher than those of the clinical view. Additionally, ment an appropriate treatment plan. Major anomalies that affect
a secondary curvature (S-shaped canal) was observed in 12.3% and endodontic practice include taurodontism, dens invaginatus, dens
23.3% of the maxillary and mandibular teeth, respectively.␣ evaginatus, extra roots (radix), and C-shaped canals.61
Root Canal Configuration Systems Taurodontism

Various classification systems have been proposed in an attempt to Taurodontism (or a “bull-shaped” tooth) is a dental morpho-
have a standardized root canal classification system that can be used logic variation in which the body of the tooth is enlarged and
by clinicians and researchers. The two most commonly used systems the roots are reduced in length.65 A taurodont tooth presents a
are the ones developed by Weine et al.,16 followed by Vertucci et al. large pulp chamber with apical displacement of the pulpal floor
(see Fig. 12.3).21 Weine’s initial classification included three types and furcation of the roots (Fig. 12.12, A and B).38 The etiol-
based on a sectioning study of the mesiobuccal root of permanent ogy of taurodontism is unclear, but it also appears in certain
maxillary first molars. The system classifies the canal configuration genetic syndromes.66 It is thought to be caused by the failure of
by two numbers. The first number is the number of canals found at Hertwig’s epithelial root sheath diaphragm to invaginate at the
the floor of the pulp chamber whereas the second number describes proper horizontal level, resulting in a tooth with normal dentin,
the canal configuration at the apex. For example, a Weine Type II short roots, elongated body, and enlarged pulp.63,64,67 The teeth
canal configuration (2-1) means that two distinct canals are found involved are almost invariably molars or rarely premolars. It can
at the floor of the pulp chamber and the two canals subsequently be uni- or bilateral and may affect single or multiple teeth.68 The
join and form a single canal at the apex. The Type IV canal con- condition may also present rarely in the primary dentition molar
figuration (1-2) was added later.52 Vertucci’s classification system teeth.69 Taurodontism is most famously reported to occur in high
A B C D E
111 1142 441-2 214 B1 P1 237 M2-1 D1
F G H I
317 MB1 DB1 P1 326 MB2-1 DB1 P1 427 MB2-1 DB1 MP1 DP1 347 M2 DB1 DL1
Three-dimensional (3D) micro–computed tomography (micro-CT) models of (A–C) single-, (D–
E) double-, and (F–I) multirooted teeth classified according to the new system proposal by Ahmed et al.59
B, Buccal; D, distal; DB, distobuccal; DL, distolingual; DP, distopalatal; M, mesial; MB, mesiobuccal; MP,
mesiopalatal; P, palatal. (Published with permission.)
incidence by Keith in 1913 as found in Homo neanderthal from a developmental defect resulting from invagination in the surface
the Krapina archaeologic find in the early 1900s.70 of the tooth crown before calcification has occurred (Fig. 12.12,
Taurodontism was classified earlier by Shaw in 1928 and has C–F).61 Clinically, it may appear as an accentuation of the lingual
been graded according to its severity: normal (cynodont), least pit in anterior teeth and, in its more severe form, gives a radio-
pronounced (hypotaurodontism), moderate (mesotaurodontism), graphic appearance of a tooth within a tooth, hence the term dens
and most severe (hypertaurodontism).71 Clinically, the crowns of in dente.38 Its etiology is controversial and remains unclear. The
these teeth usually have normal characteristics. Therefore the diag- affected teeth radiographically show an infolding of enamel and
nosis is entirely radiologic.68 Owing to the complexity of the root dentin that may extend deep into the pulp cavity and into the
canal anatomy and the proximity of the orifices to the root apex, root and sometimes even reach the root apex.74 The most com-
complete filling of the root canal system in taurodontism is chal- mon associated clinical finding is an early pulpal involvement,
lenging. Because the pulp of a taurodont is usually voluminous, explained by the existence of a canal extending from the invagi-
control of bleeding in cases of pulpitis may take some time and nation into the pulp.75 The invagination also allows the entry of
effort compared to teeth with normal anatomy. Additional efforts irritants into an area that is separated from pulpal tissue by only a
such as application of ultrasonic instrumentation combined with thin layer of enamel and dentin and presents a predisposition for
sodium hypochlorite (NaOCl) as an irrigant solution should be the development of dental caries.74 Therefore this condition must
made to dissolve as much organic material as possible.68,72,73␣ be recognized early and the tooth prophylactically restored.73 The
variability of its root canal system configuration is unlimited.
Clinically, however, it can only be speculated upon from radio-
Dens Invaginatus and Dens Evaginatus graphs.76 In this way, the most commonly referred classification
Dens invaginatus (dens in dente, dilated composite odontome, was proposed by Oehlers,77 who categorized it into three types:
dilated odontome, gestant anomaly, invaginated odontome,
dilated gestant odontome, tooth inclusion, dentoid in dente) is
T: 0,15mm A
30
20
R
10
C D P
T T: 0,15mm A
30
R 20
10
A B E F
G H I
Root canal anomalies and embryologic malformations. (A–B) Taurodont maxillary second
molar presenting a large pulp chamber (yellow arrow) with apical displacement of the pulpal floor and furcation of
the roots; C–F, Clinical and tomographic views of a maxillary lateral incisor with dens invaginatus (arrows) (Cour-
tesy of Dr. Oscar von Stetten. Published with permission); G–I, Clinical and radiographic views of a mandibular
second premolar with dens evaginatus (arrows). (Courtesy Dr. Daniela Bololoi. Published with permission.)
the CEJ and does not involve the periradicular tissues, but may when the root apex closure has not occurred in the young patient.
It is important for the clinician to be able to recognize and treat
extends beyond the CEJ and may present a second apical foramen, the entity soon after affected teeth have erupted into the oral cav-
with no immediate communication with the pulp. In the litera- ity in order to avoid the development of pathologic conditions.82␣
ture, the reported prevalence of this anomaly varies from 0.25%78
to 10%79 and the most affected teeth are permanent maxillary Radix
lateral incisors, despite the fact that it may occur in any tooth.74,80
This high range frequency of dens invaginatus has been associated Radix is a Latin word for “root” and is referred to additional roots
with the study design, sample size and composition, and diagnos- of teeth, mostly molars. In radix molars, each root usually con-
tic criteria.74,75 tains a single root canal.61
Dens evaginatus is an anomalous outgrowth of tooth structure In four-rooted maxillary molars, the palatal part of the root
resulting from the folding of the inner enamel epithelium into complex is made up of two macrostructures located mesially and
the stellate reticulum with the projection of structure exhibiting distally, which are in principle cone-shaped and either separate or
enamel, dentin, and pulp tissue (Fig. 12.12, G–I).38 It arises most nonseparate in relation to each other.85 If the mesial of the two
frequently from the occlusal surface of involved posterior teeth, palatal root structures has direct affinity to the mesiolingual part
mainly maxillary and mandibular premolars, and primarily from of the crown, which is more pronounced, the mesial root structure
the lingual surface of associated anterior teeth (called talon cusps is identified as radix mesiolingualis, whereas the distal structure is
when in this location).81,82 Its etiology remains unclear. However, identical with the palatal root component. If the distal of the two
it predominantly occurs in people of Asian descent with varying palatal root structures has direct affinity to the distopalatal part
estimates reported at 0.5%83 to 15%,84 depending on the popu- of the crown, the distal root structure is identified as radix disto-
lation group studied. The presence of pulp within the cusp-like lingualis, whereas the mesial structure is identical with the palatal
tubercle has great clinical significance. Because the tubercle may root component (Fig. 12.13).86
extend above the occlusal surface, malocclusion or attrition with In mandibular molars, additional roots have been identified as
the opposing tooth may cause abnormal wear or fracture of the radix entomolaris and radix paramolaris.61,87 Radix entomolaris
tubercle, and this is how pulp exposure occurs.82 Subsequent has been defined as a supernumerary root on a mandibular molar
pulpal inflammation or infection will most likely ensue, at times located distolingually (Fig. 12.14), whereas radix paramolaris is
MB RML
DB RDL RDL RML

DB RDL
RML
MB DB
RDL
Different views of a three-dimensional (3D) micro–computed tomography (micro-CT) models of

the external and internal morphologies of a four-rooted maxillary molar showing radix mesiolingualis (RML)
and radix distolingualis (RDL). DB, Distobuccal root; MB, mesiobuccal root.
Buccal View Distal view Lingual View
Occlusal View
Mesial View ML
MB
FRONTAL VIEW
LATERAL VIEW
Three-dimensional (3D) micro–computed tomography (CT) models of the external and internal
morphologies of mandibular second molars showing radix entomolaris (yellow arrows). In the lateral view,
the curvature of the radix is depicted (black arrows).
Radiographic and tomographic views of a mandibular left second premolar showing a radix
paramolaris (arrows), before and after root canal treatment. (Courtesy Dr. Nuno Pinto. Published with
permission.)
an extra root located mesiobuccally (Fig. 12.15).38 The presence opening cavity. An accurate diagnosis of these anatomic variations
of these anatomic anomalies has been associated with certain is important to avoid missed canals.87␣
ethnic groups such as Sino Americans, which include Chinese,
Inuit, and American Indians.88,89 Radix paramolaris is a very rare C-Shaped Canals
structure and its prevalence was found to be 0%, 0.5%, and 2.0%
for the mandibular first, second, and third molars, respectively,90 The C-shaped configuration was first reported in the endodontic
whereas radix entomolaris occurs with a higher frequency, rang- literature by Cooke and Cox in 1979,93 but this canal configura-
ing from 0.2%91 to 32%92 of the studied samples. The orifice tion has been well-known since the beginning of the 20th cen-
of the radix entomolaris is located disto- to mesiolingually from tury.94 This anatomic variation is so named for the root and root
the main canal or canals of the distal root, whereas the orifice of canal cross-sectional shape of the capital letter “C.”95 Its main
the radix paramolaris is located mesio- to distobuccally from the anatomic feature is the presence of one or more isthmuses con-
main mesial canals.88 A dark line or groove from the main root necting individual canals, which can change the cross-sectional
canal on the pulp chamber floor leads to these orifices89; how- and 3D canal shape along the root (Fig. 12.16).95-97 Typically,
ever, they provide a limited practical aid for its identification in this configuration is found in teeth with fusion of the roots either
clinical practice. These anatomic variations present definite chal- on its buccal or lingual aspect, and results from the failure of
lenges to therapy because of their orifice inclination and root canal Hertwig’s epithelial root sheath to develop or fuse in the furcation
curvature. In this way, preoperative periapical radiographs at dif- area during the developing stage of the teeth.63,64 Failure on the buc-
ferent horizontal angles or a CBCT examination are required to cal side will result in a lingual groove, and the opposite cases would be
identify this additional root, which will also result in a modified possible.63 In such teeth, the floor of the pulp chamber is frequently
It is important to point out that mandibular molar teeth

can present with irregularities in their canal systems throughout
the root and the presence of these categories may vary from the
pulp chamber to the apex.106 In this way, Fan et al.110 modified
Melton’s method and recommended to classify each portion of the
same tooth using five categories:
separation or division.
from a discontinuation of the “C” outline.
-
tion (normally found near the apex)
Melton’s classification96 stated that categories II and III have

separated canals, but no description was provided to differentiate
them. In the modified classification,110 one of the canals in the
category II would appear as an arc and would be more likely to
extend into the “fused” area of the root where the dentin wall may
be quite thin.
C-shaped canal anatomy has also been reported in third molars,111
lateral incisors,102 mandibular first premolars,97,99,101,112,113 man-
dibular first molars,114 and maxillary first115,116 and second117
molars. Recently the prevalence of C-shaped canal configuration
in maxillary molars with root fusion was reported to be as high
as 15% (Fig. 12.17, A).115 Mandibular first premolars present a
variety of root canal configurations that include the presence of
two or three root canals40,113 and a C-shaped configuration sys-
tem (Fig. 12.17, B).118 As in mandibular molars, C-shaped canal
systems in the mandibular first premolars vary among different
ethnic groups, with its prevalence being reported to range from
1%119 to 18%.120 This configuration has been highly associated
with Vertucci’s type V configuration100 (i.e., a single canal that
bifurcates at the middle third and with the presence of a groove or
Three-dimensional (3D) micro–computed tomography (CT)
concavity on the external root surface).97,113 Radicular grooves on
models of the external and internal morphologies of mandibular second
molars showing different C-shaped canal configurations.
mandibular first premolars usually begin 3 mm from the CEJ and
present frequently on the proximal lingual area of the middle root,
not always extending to the root apex.97,120
situated deeply and may assume an unusual anatomic appearance.97 Preoperative diagnosis of C-shaped canals is complex, mainly
Below the orifice level, the root structure of a C-shaped tooth can because these unique anatomic features are not easily recognized
harbor a wide range of anatomic variations,95 which make it a chal- on a traditional 2D periapical radiograph.98 With the increased
lenge with respect to disinfection.98 This variation may occur in dif- use of CBCT scanning, clinicians may be able to detect C-shaped
ferent types of teeth97,99-102; however, it is most commonly found in canals before endodontic treatment. Nevertheless, even when
mandibular second molars103,104 with a reported prevalence rang- recognized, the disinfection procedure still remains a challenge,
ing from 2.7%105 to 44.5%.106 There is significant ethnic variation mostly because of the isthmus areas. Irregular areas in a C-shaped
in the frequency of C-shaped molar teeth, which are much more canal that may house soft tissue remnants or infected debris may
common in Asian populations than in Caucasian populations.30 escape thorough cleaning and may be a source of bleeding and
In population-based studies, the reported prevalence was 10.6% in severe pain.121 In this way, the use of a dental microscope asso-
Saudi Arabians,107 19.14% in Lebanese,108 31.5% in Chinese,104 ciated with sonic or ultrasonic instrumentation techniques may
and 44.5% in Koreans.106 To date, two studies have addressed the make treatment outcome more predictable.30 Because of its chal-
efficacy of different systems in the preparation of C-shaped man- lenging morphology, the C-shaped canal anatomy increases the
dibular molar canals showing a significant percentage of canal area difficulty in root canal therapy and may account for the frequent
unaffected by the instrumentation procedure.98,109 occurrence of endodontic failure on this tooth.120␣
In 1991 Melton et al.96 proposed the first classification for
C-shaped canal configuration in mandibular second molars Other Anomalies
based on its cross-sectional shape. They fall into three catego-
(1) Fusion: It is commonly defined as the union of two distinct
dental sprouts that occurs in any stage of the dental organ.38
orifice in which dentin separates a main C-shaped canal from They are joined by the dentin, whereas pulp chambers and ca-
nals may be linked or separated depending on the developmen-
and separate canals which could join in the apical (subdivision tal stage when the union occurs. This process involves epithe-
I), middle (subdivision II), or coronal (subdivision III) thirds. lial and mesenchymal germ layers resulting in irregular tooth
A
A, Three-dimensional (3D) models and two-dimensional (2D) cross-sections of maxillary sec-
ond molars with fused roots. Note the complexity of the root canal system with the presence of canal
interconnections, apical ramifications and C-shaped canals; B, 3D model and 2D cross-sections at differ-
ent levels of the root of a mandibular first premolar with radicular groove and C-shaped canal configuration.
morphology and occurs more frequently in anterior teeth (Fig. tion, such as Paget disease, acromegaly, or vitamin A deficiency
12.18).122 (Fig. 12.19).123
(2) Gemination: It is a disturbance during odontogenesis in (4) Radicular Groove: This is a developmental depression in the
which partial cleavage of the tooth germ occurs and results proximal aspect of the root surface.124 Radicular grooves
in a tooth that has a double or “twin” crown, usually not have been reported as being widespread in Africans and
completely separated, and sharing a common root and pulp native Australians and are relatively rare in Western Eur-
space (see Fig. 12.18).38 The root and pulp are also irregular asians.125 It is relevant in clinic care because its depth may
in morphology. act as a reservoir for dental plaque and calculus, increasing
(3) Hypercementosis: This refers to an excessive deposition of the difficulty in the management of periodontal disease.97,101
nonneoplastic cementum over normal root cementum, which In mandibular premolar teeth, its presence has been associ-
alters the root morphology macroscopic appearance.38 Its ated with anatomic complexities of the root canal system,
pathogenesis is ambiguous. Most of the cases are idiopathic. such as canal bifurcation and C-shaped configuration (Fig.
Several local and systemic factors are also linked to this condi- 12.20).97,99,101␣
Fusion Gemination
Fusion Gemination
A B
A, Clinical and B, tomographic views of a patient presenting fusion and gemination at the
anterior teeth. (Courtesy Dr. Antonis Chaniotis. Published with permission.)
Coronal and sagittal cone beam computed tomography (CBCT) images from a distal root of
a mandibular first molar presenting hypercementosis (arrow). (Courtesy Dr. Oscar von Stetten. Published
with permission.)
Aging
contradictory information can be found. While in mandibular ante-
The root canal anatomy is susceptible to changes over the years rior teeth most studies reported a lower prevalence of multiple canals
because of physiologic or pathologic events. Natural physiologic in older patients,130,131 in maxillary and mandibular premolars and
aging tends to modify the root canal system morphology as a result in mandibular molars128,132 it was observed that there was a progres-
of the deposition of secondary dentin, which starts to form once the sive decrease of Vertucci’s Type I configuration with age. The preva-
tooth erupts and is in occlusion.126 Consequently, young patients lence of a second canal in the mesiobuccal root of maxillary first and
tend to present with large single canals and pulp chambers,127,128 second molars was also evaluated and most studies reported a lower
whereas older patients tend to present with more sharply defined prevalence of this configuration in older patients.129,133-135␣
and narrow root canals.127 Other pathologic or iatrogenic factors can
also modify the deposition of dentin including occlusal trauma, peri-
odontal disease, carious lesions, or deep restorative procedures.129 Root Canal Anatomy of Maxillary and
In the literature, CBCT imaging technology has been also used Mandibular Teeth
to address in vivo root canal morphologic changes caused by aging.3
Overall, results showed no significant difference between maxil- In this section, illustrations and tables of the characteristics of the
lary and mandibular anterior teeth groups regarding age, despite anatomy of the human root and root canals are depicted. The teeth
A B
A, Three-dimensional (3D) micro–computed tomography (micro-CT) models of mandibular
premolars showing the external anatomy with the presence of radicular grooves (arrows); B, Two-dimen-
sional (2D) cross-section of the root of a mandibular premolar showing radicular groove (arrow) and a
C-shaped canal configuration.
are paired to facilitate comparison among groups. Root and canal identified root form variation.1 A higher incidence of the disto-
number averages are calculated from a weighted average of a large lingual root of both first and second mandibular molar teeth in
number of dental anatomy research articles published from a num- Asian and North American aboriginal native populations is a good
ber of sources. Other data listed describe the canal characteristics example. There have been only a few studies that show a variation
such as average length of root and crown, canal curvature direction, in incidence that is gender linked.137-139 More recently, a series
canal shape, lateral canals, and apical anastomoses. Most important of epidemiologic studies on root canal anatomy using CBCT
is the listing of the most common anomalies or variation from the 3D imaging technology have been published. The most impor-
normal that may be found in that tooth type. Those data are usually tant advantage of using CBCT is the possibility of performing
present in numerous case reports from a PubMed search.3,136 in vivo studies analyzing the full dentition of a large number of
Of great interest, not only to dentists but also to the science of patients collected from a specific population in a consecutive man-
physical anthropology, are the ethnic variations that can be found ner, addressing the influence of several variables such as ethnicity,
in human populations.11 It is true that genetics plays the main role aging, gender, and side (left or right) on teeth. Therefore, infor-
in determining the shape of a crown and root. Bilateral symmetry mation regarding the number of roots and root canals and the
is usually present in the antimere of the opposite quadrant but not most frequently observed canal configurations was depicted from
necessarily so when it comes to variation in root number or anom- a recent epidemiologic study using CBCT technology.3
alous tooth formation. A suite of dental variations in crown and The following tables and figures will help outline the com-
root anatomy may be used to indicate ethnic identity in a popula- mon characteristics of each tooth type and list some variations or
tion when a number of characteristics appear in a higher incidence anomalies.
of that population. The dental characteristics that are of interest
to a physical anthropologist include deep lingual fossa (shoveling) Incisors
of anterior teeth, dens invaginatus, dens evaginatus (talon cusp
and occlusal tubercles of premolar teeth), bifurcated roots of man- Morphologic aspects of the root and root canal anatomy of max-
dibular canines, three roots of maxillary premolar teeth, fusion or illary and mandibular incisors are detailed in Table 12.1, Fig.
single root of the maxillary premolar, multiple roots or multiple 12.21, and Appendices 1 to 4 (Summary of Root Numbers and
canals of mandibular premolar teeth, C-shaped molar teeth, taur- Root Canal Systems of the Permanent Teeth).
odontism, fusion of roots, double canals in palatal or distal root of The maxillary central incisors are centered in the maxilla, one
maxillary molars, four roots with double palatal root in maxillary on either side of the midline, with the mesial surface of each in
second molar teeth, and radix entomolaris or the distolingual root contact with the mesial surface of the other. The pulp cavity fol-
of mandibular molar teeth. lows the general outline of the crown and root. In this way, the
Tratman in 195011 used extracted teeth to show a number of pulp chamber is very narrow in the incisal region and wider in
variations or traits in dental anatomy in Asian populations that the mesiodistal dimension than in the labiolingual dimension.
varied from the generally accepted Western Eurasian dental anat- The maxillary lateral incisor supplements the central incisor in
omy of the time. Since then, many large population studies using function, and the crowns bear a close resemblance. However, the
full mouth radiographs or the panographic X-ray technique have lateral incisor is smaller in all dimensions except root length.
TABLE
12.1
Maxillary Central Incisor Maxillary Lateral Incisor Mandibular Incisors
Overall length 23.6 mm (16.5-32.6 mm) 22.5 mm (17.7-28.9 mm) C: 20.8 mm (16.9-26.7 mm)
L: 22.1 mm (18.5-26.6 mm)
Root length 13.0 mm (6.3-20.3 mm) 13.4 mm (9.6-19.4 mm) C: 12.6 mm (7.7-17.9 mm)
L: 13.5 mm (9.4-18.1 mm)
Number of roots 1 (99.94%) 1 (99.94%) C: 1 (100%)
2 (0.06%) 2 (0.06%) L: 1 (99.92%)
2 (0.08%)
Number of canals 1 (99.2%) 1 (98.5%) C: 1 (86.5%)
2 (0.8%) 2 (1.5%) 2 (14.4%)
Other (0.1%)
L: 1 (79.7%)
2 (20.2%)
Other (0.1%)
Canal configuration Types I (99.2%) Types I (98.5%) C: Types I (86.5%)
IV (0.5%) II (0.8%) III (8.1%)
II (0.1%) V (0.4%) V (2.8%)
III (0.1%) III (0.2%) II (2%)
V (0.1%) IV (0.1%) IV (1.4%)
VII (0.1%)
Other (0.1%)
L: Types I (79.7%)
III (11.9%)
V (3.8%)
II (2.6%)
IV (1.8%)
VII (0.1%)
Other (0.1%)
Accessory canals 18.9%-42.6% (coronal: 1%; middle: 5.5%-26% (coronal: 1%; middle: 8%; C: 0%-20% (coronal: 3%; middle:
6%; apical: 93%) apical: 91%) 12%; apical: 85%)
L: 0.9%-18% (coronal: 2%; middle:
15%; apical: 83%)
Apical curvature Straight (75%) Labial (9.3%) Distal Distal (49.2%) Straight (29.7%) Pala- C: Straight (66.7%) Labial (18.8%)
(7.8%) Mesial (4.3%) Palatal tal (3.9%) Labial (3.9%) Mesial Distal (12.5%)
(3.6%) (3.1%) S-shaped (2%)
S-shaped (1.6%) Other (8.6%) L: Straight (54%) Distal (33.3%)
Labial (10.7%)
S-shaped (2%)
Anomalies 2 canals141-143 2 canals148 3 canals155
3 canals144 3 canals149 Fusion/gemination156
4 canals145 4 canals150 Dens invaginatus157
2 roots141-143 2 roots151 2 roots158
Radicular groove146 Radicular groove146
Fusion/gemination147 Fusion/gemination152
Dens invaginatus153
Dens evaginatus154
C-shaped102
Ethnic variations Deep lingual fossa (shoveling) in Coronal shoveling present to a lesser
Asian and North American native degree
populations
C, Central; L, lateral.
Root canal configurations are classified according to Vertucci.40
Adapted from Versiani MA, Pereira MR, Pécora JD, Sousa Neto MD: Root canal anatomy of maxillary and mandibular teeth. In Versiani MA, Basrani B, Sousa Neto MD, editors: The root canal anatomy in
permanent dentition, ed 1. Switzerland, 2018, Springer International Publishing, pp 181–240.
Maxillary Central Incisor Mandibular Central Incisor
Frontal View Lateral View Coronal Third Frontal View Lateral View Coronal Third
Middle Third Middle Third
Apical Third Apical Third
Maxillary Lateral Incisor Mandibular Lateral Incisor
Three-dimensional (3D) micro–computed tomography (micro-CT) models and two-dimensional

(2D) cross-sections depicting the internal and external anatomy of maxillary and mandibular incisors.
The pulp chamber is narrow in the incisal region and may become in contact with the mesial surface of the other. The right and left
very wide at the cervical level of the tooth, whereas pulp horns are mandibular lateral incisors are distal to the central incisors. The man-
usually prominent.140 dibular central and lateral incisors have smaller mesiodistal dimen-
The mandibular central incisors are centered in the mandible, one sions than any of the other teeth. The central incisor is somewhat
on either side of the midline, with the mesial surface of each one smaller than the lateral incisor, which is the reverse of the situation in
TABLE
12.2
Maxillary Canine Mandibular Canine
Overall length 26.4 mm (20.0-38.4 mm) 25.9 mm (16.1-34.5 mm)
Root length 16.5 mm (10.8-28.5 mm) 15.9 mm (9.5-22.2 mm)
Number of roots 1 (100%) 1 (98.57%)
2 (1.43%)
Number of canals 1 (97%) 1 (92.4%)
2 (3%) 2 (7.3%)
Other (0.3%)
Canal configuration Types I (98.5%) Types I (92.4%)
III (1.2%) III (2.7%)
II (0.8%) II (1.9%)
V (0.7%) IV (1.5%)
IV (0.2%) V (1.2%)
Other (0.1%) Other (0.3%)
Accessory canals 3.4%-30% (coronal: 0%; middle: 10%; apical: 4.5%-30% (coronal: 4%; middle: 16%; apical:
90%) 80%)
Apical curvature Straight (38.5%) Straight (68.2%)
Distal (19.5%) Distal (19.6%)
Labial (12.8%) Labial (6.8%)
Mesial (12%) Mesial (0.8%)
Palatal (6.5%) S-shaped (1.5%)
Other (10.7%) Other (3.1%)
Anomalies 2 canals159 2 canals161
Dens invaginatus160 3 canals162
2 roots161
Ethnic variations Bifurcated roots in mandibular canines are most
common in some Western Eurasian populations

Adapted from Versiani MA, Pereira MR, Pécora JD, Sousa Neto MD: Root canal anatomy of maxillary and mandibular teeth. In Versiani MA, Basrani B, Sousa Neto MD, editors.: The root canal anatomy in
permanent dentition. ed 1. Switzerland, 2018, Springer International Publishing, pp 181–240.
the maxilla. These teeth are similar in form and have smooth crown closely to the outline of the tooth, the size of the pulp chamber
surfaces that show few traces of developmental lines. The mandibular may also be the largest in the mouth.
central incisor is the smallest tooth in the mouth, but its labiolingual The mandibular canine crown is narrower mesiodistally than that
root dimension is large. This tooth usually has one canal. Two ribbon- of the maxillary canine, although it is just as long in most instances
shaped canals may be found, but not very frequently (15% and 20% and, in many instances, is longer by 0.5 to 1 mm. The root may be as
of central and lateral incisors, respectively). The pulp horns are well long as that of the maxillary canine, but usually it is somewhat shorter.
developed in this tooth group. The mandibular lateral incisor tends to The pulp cavity of the mandibular canine tends to be a little shorter
be a little larger than the mandibular central incisor in all dimensions, than that of the maxillary canine. A not rare variation in the form of
including the pulp chamber. The pulp canal may taper gently from the mandibular canine is bifurcated roots, and it is also not uncom-
the apex or narrow abruptly in the last 3 to 4 mm of the root canal.140␣ mon to find two roots or at least two canals. Because the presence of
two canals cannot be easily detected radiographically, their presence
must be ruled out clinically as well. Some mandibular canines demon-
Canines strate an abrupt narrowing of the pulp cavity when passing from the
Morphologic aspects of the root and root canal anatomy of maxil- pulp chamber to the pulp canal. Other mandibular canine teeth dem-
lary and mandibular canines are detailed in Table 12.2, Fig. 12.22, onstrate an abrupt narrowing of the pulp canal in the apical region.140␣
and Appendices 1 to 4 (Summary of Root Numbers and Root
Canal Systems of the Permanent Teeth). Premolars
Maxillary canines are the longest teeth in the mouth. The
crowns are usually as long as those of the maxillary central incisors, Morphologic aspects of the root and root canal anatomy of maxil-
and the single roots are longer than those of any of the other teeth. lary and mandibular premolars are detailed in Tables 12.3 and
Therefore the maxillary canine has the largest labiolingual root 12.4, Fig. 12.23, and Appendices 1 to 4 (Summary of Root Num-
dimension of any tooth and because the pulp cavity corresponds bers and Root Canal Systems of the Permanent Teeth).
Maxillary Canine Mandibular Canine

Three-dimensional (3D) micro–computed tomography (micro-CT) models and two-dimen-

sional (2D) cross-sections depicting the internal and external anatomy of maxillary and mandibular canines.
TABLE
12.3
Maxillary First Premolar Maxillary Second Premolar
Number of roots 2 (55.3%) 1 (86.2%)
1 (43.1%) 2 (13.5%)
3 (1.6%) 3 (0.3%)
Number of canals 2 (77.3%) 2 (56.7%)
1 (20.1%) 1 (42.7%)
3 (1.2%) 3 (0.4%)
Canal configuration Types IV (50.1%) Types I (42.7%)
I (20.1%) II (18.7%)
II (17.4%) IV (17.6%)
VI (4.9%) V (9.6%)
V (3%) VI (6.3%)
III (1.5%) III (4%)
VIII (1.2%) VII (0.5%)
VII (0.4%) VIII (0.4%)
Accessory canals 17.8%-49.5% (coronal: 4.7%; middle: 10.3%; apical: 74%) 12.9%-59.5% (coronal: 4%; middle: 16.2%;
apical: 78.2%)
Apical curvature B: Palatal (36.2%) Straight (37.4%)
Straight (27.8%) Distal (29.5%)
Distal (14%) Buccal (15.7%)
Buccal (14%) S-shaped (13%)
S-shaped (8%) Distal (4.4%)
P: Straight (44.4%)
Buccal (27.8%)
Distal (14%)
Palatal (8.3%)
S-shaped (5.5%)
Continued
TABLE
12.3
Maxillary First Premolar Maxillary Second Premolar
Radicular groove164 Dens invaginatus167
Fusion/gemination165
Dens evaginatus166
Ethnic variations Caucasian and other populations (excluding Asian and North American native
populations) most commonly have 2 roots. Asian and North American native
populations most commonly have a single root. Dens evaginatus on the occlu-
sal surfaces of all premolars is more common in Asian and North American
native populations
B, Buccal root/canal; P, palatal root/canal.

Adapted from Versiani MA, Pereira MR, Pécora JD, Sousa Neto MD: Root canal anatomy of maxillary and mandibular teeth. In: Versiani MA, Basrani B, Sousa Neto MD, editors. The root canal anatomy in
TABLE
12.4
Mandibular First Premolar Mandibular Second Premolar
Number of roots 1 (97.5%) 1 (98.5%)
2 (2.5%) 2 (1.5%)
Number of canals 1 (71.3%) 1 (84.7%)
2 (27.9%) 2 (15.05%)
3 (0.1%) 3 (0.05%)
Canal configuration Types I (71.3%) Types I (84.7%)
V (18.7%) V (13.44%)
IV (3.5%) II (0.7%)
III (2.8%) III (0.5%)
II (2.3%) IV (0.3%)
VI (0.5%) VI (0.07%)
VII (0.1%) VIII (0.05)
VIII (0.1%) VII (0.04%)
Accessory canals 8.8%-44.3% (coronal: 4.3%; middle: 16.1%; apical: 78.9%) 4%-48.3% (coronal: 3.2%; middle: 16.4%; apical: 80.1%)
Apical curvature Straight (47.5%) Distal (39.8%)
Distal (34.8%) Straight (38.5%)
Lingual (7.1%) Buccal (10.1%)
Buccal (2.1%) Lingual (3.4%)
S-shaped (6.4%) S-shaped (6.8%)
4 canals168 4 canals173
Radicular groove112 5 canals174
C-shaped97 2 roots175
Dens evaginatus169 C-shaped99
Dens invaginatus170 Dens evaginatus176
Fusion/gemination171 Taurodontism174
Fusion/gemination177
Ethnic variations African American population has a significantly higher incidence
of two canals and two roots compared with Caucasian1

Adapted from Versiani MA, Pereira MR, Pécora JD, Sousa Neto MD: Root canal anatomy of maxillary and mandibular teeth. In: Versiani MA, Basrani B, Sousa Neto MD, editors. The root canal
anatomy in permanent dentition. ed 1. Switzerland, 2018, Springer International Publishing, pp 181–240.
Maxillary First Premolar Mandibular First Premolar

B
B
P
P
Maxillary Second Premolar Mandibular Second Premolar

P
B
Three-dimensional (3D) micro–computed tomography (micro-CT) models and two-dimensional

(2D) cross-sections depicting the internal and external anatomy of maxillary and mandibular premolars.
The premolars are so named because they are anterior to the larger in those dimensions. Usually the root of the second premo-
molars in the permanent dentition. The maxillary first premolar lar is as long as, if not a millimeter or so longer than, that of the
has two cusps, a buccal and a lingual, each being sharply defined. first premolar. Most maxillary second premolars have only one
The buccal cusp is usually about 1 mm longer than the lingual root and canal. Two roots are possible, although two canals within
cusp and, because of that, the pulp horn usually extends further a single root may also be found. The pulp cavity may demonstrate
occlusally under the buccal cusp than the lingual cusp. The maxil- well-developed pulp horns; others may have blunted or nonexis-
lary first premolar may have two well-developed roots, two root tent pulp horns. The pulp chamber and root canal are very broad
projections that are not fully separated, or one broad root. The in the buccolingual aspect of teeth with single canals.140
majority of maxillary first premolars have two root canals, but a The mandibular first premolar is always the smallest of the
small percentage of teeth may have three roots and three canals two mandibular premolars, whereas the opposite is true, in many
that may at times be difficult to see or almost undetectable radio- cases, of the maxillary premolars. Most of these teeth have one
graphically. The pulp chamber floor is below the cervical level of canal, but two or three canals are possible. The pulp chamber is
all the variations found in this tooth group. usually very large, and the pulp cavity may taper gently toward the
The maxillary second premolar supplements the maxillary first apex or abruptly as the root canal start. The root of the first pre-
premolar in function and closely resembles it in shape. The maxil- molar usually shows a deep developmental groove that has been
lary second premolar may have a crown that is noticeably smaller associated with complex anatomic features including C-shaped
cervico-occlusally and also mesiodistally. However, it may also be and extra root canals.140
The mandibular second premolar usually has three well-formed The mandibular first molar is usually the largest tooth in the
cusps in most cases: one large buccal cusp and two smaller lin- mandibular arch. It has five well-developed cusps, two well-devel-
gual cusps. However, two-cusped forms of this tooth are also fairly oped roots, one mesial and one distal, which are very broad buc-
common. It usually has one root and canal that may be curved, colingually. These roots are widely separated at the apices. The
usually in the distal direction. The pulp horns are prominent, and buccolingual cross-section of the mandibular first molar demon-
the pulp chamber and root canal gently taper toward the apex. The strates a large pulp chamber that may extend well down into the
single root of the second premolar is larger and longer than that of root formation. The mesial root usually has a more complicated
the first premolar. The root is seldom, if ever, bifurcated, although canal system because of the presence of two canals and their inter-
some specimens show a deep developmental groove buccally.140␣ connections. The distal root usually has one large canal, but two
canals are often present. Occasionally, a fourth canal is present
that has its own separate root.
Molars Normally, the mandibular second molar has four well-
Morphologic aspects of the root and root canal anatomy of max- developed cusps, two buccal and two lingual, of nearly equal
illary and mandibular first and second molars are detailed in development. The tooth has two well-developed roots, one
Tables 12.5, 12.6, Figs. 12.24 and 12.25, and Appendices 1 to mesial and one distal. These roots are broad buccolingually, but
4 (Summary of Root Numbers and Root Canal Systems of the they are not as broad as those of the first molar, nor are they as
Permanent Teeth). widely separated. The buccolingual section of the mandibular
The maxillary molars are the largest and strongest maxillary second molar demonstrates a pulp chamber and pulp canals
teeth, by virtue both of their bulk and of their anchorage in the that tend to be more variable and complex than those found in
jaws. The crown of this tooth is wider buccolingually than mesio- the mandibular first molar.140
distally. The maxillary first molar is normally the largest tooth in In the literature, first and second permanent molars are the
the maxillary arch. It has four well-developed functioning cusps most studied teeth in relation to internal and external anatomy.
and one supplemental cusp (the cusp of Carabelli) that is of little On the other hand, considering that third molars have variable
practical use. The maxillary first molar normally has three roots and unpredictable morphology and also because their extraction
and four canals. The palatal root usually has the largest dimen- is frequently indicated, these teeth are rarely considered for end-
sions, followed by the mesiobuccal and distobuccal roots, respec- odontic or restorative treatment. Therefore only a limited number
tively. The mesiobuccal root is often very wide buccolingually and of studies have reported data regarding the internal and external
normally possesses an extra accessory canal named MB2, which morphology of third molars. In general, these studies show an
usually is the smallest of all the canals in this tooth.140 The com- extremely varied anatomy, with maxillary third molars having one
plexity of its root canal system may surpass all other teeth within to five roots with one to six root canals, whereas the mandibular
the human dentition. More extensive use of the clinical micro- third molars have one to four roots and one to six root canals,
scope has contributed to the discovery that not only a fourth canal besides the presence of C-shaped canals. In addition, maxillary
but other additional canals also may exist. and mandibular third molars present a high incidence of fused
The maxillary second molar supplements the first molar in roots, with an average of 70.1% and 40.7%, respectively, which
function. The roots of this tooth are as long as, if not somewhat explains their variations in number, morphology, direction, and
longer than, those of the first molar. The tendency for root fusion arrangement of roots and canals (Table 12.7).
is greater in the second maxillary molar than in the first maxillary Finally, Table 12.8 shows the outcomes from epidemiologic
molar, but the palatal root is usually separate. Most often maxil- studies using CBCT in large populations, in which both data from
lary second molars possess three roots and three canals. The mesio- root and root canal anatomy were evaluated, selected, and com-
buccal root of the maxillary second molar is not as complex as that bined, aiming to offer an overview of the percentage frequency of
formed in the maxillary first molar. The tendency for a very wide different number of roots and root canal configuration types in all
mesiobuccal canal is not present in this tooth group.140 groups of teeth.␣
TABLE
12.5
Maxillary First Molar Maxillary Second Molar
Root length MB:12.9 mm (8.5-18.8 mm) MB: 12.9 mm (9.0-18.2 mm)
DB: 12.2 mm (8.9-15.5mm) DB: 12.1 mm (9.0-16.3mm)
P: 13.7 mm (10.6-17.5 mm) P: 13.5 mm (9.8-18.8 mm)
Number of roots 3 (97.7%) 3 (73.7%)
2 (1.8%) 2 (14.9%)
4 (0.3%) 1 (10.7%)
1 (0.2%) 4 (0.7%)
TABLE
12.5
Maxillary First Molar Maxillary Second Molar
Number of canals MB: 2 (60.4%) MB: 1 (66.1%)
1 (29.3%) 2 (33.7%)
3 (0.1%) 3 (0.05%)
DB: 1 (98.6%) DB: 1 (99.6%)
2 (1.4%) 2 (0.4%)
P: 1 (99.26%) P: 1 (99.67%)
2 (0.7%) 2 (0.35%)
Other (0.04%) 3 (0.01%)
Other (0.01%)
Canal configuration MB: Types I (39.1%) MB: Types I (39.1%)
II (29.3%) II (29.3%)
IV (26%) IV (26%)
V (2%) V (2%)
III (1.6%) III (1.6%)
VI (1.4%) VI (1.4%)
VII (0.1%) VII (0.1%)
VIII (0.1%) VIII (0.1%)
DB: Types I (98.6%) DB: Types I (98.6%)
II (0.4%) II (0.4%)
V (0.4%) V (0.4%)
III (0.3%) III (0.3%)
IV (0.2%) IV (0.2%)
VI (0.1%) VI (0.1%)
P: Types I (99.26%) P: Types I (99.26%)
II (0.3%) II (0.3%)
III (0.2%) III (0.2%)
IV (0.1%) IV (0.1%)
V (0.1%) V (0.1%)
Other (0.04%) Other (0.04%)
Accessory canals MB: 51% MB: 50%
(coronal: 10.7%; middle: 13.1%; apical: 58.2%) (coronal: 10.1%; middle: 14.1%; apical: 65.8%)
DB: 36% DB: 29%
P: 48% P: 42%
Apical Curvature MB: Distal (78%) MB: Distal (54%)
Straight (21%) Straight (22%)
S-shaped (1%) Others (24%)
DB: Straight (54%) DB: Straight (54%)
Mesial (19%) Mesial (17%)
Distal (17%) Others (29%)
S-shaped (10%) P: Straight (63%)
P: Buccal (55%) Buccal (37%)
Straight (40.7%)
Mesial (3.2%)
Distal (1.1%)
Anomalies 1 canal178 1 or 2 canals183
6 canals180 Fusion/gemination185
7 canals181 Taurodontism186
8 canals182
C-shaped116
4 roots85
Taurodontism68
Ethnic variations
MB, Mesiobuccal root/canal; DB, distobuccal root/canal; P, palatal root/canal.

Adapted from Versiani MA, Pereira MR, Pécora JD, Sousa Neto MD: Root canal anatomy of maxillary and mandibular teeth. In Versiani MA, Basrani B, Sousa Neto MD, editors. The root canal anatomy in
TABLE
12.6
Mandibular First Molar Mandibular Second Molar
Root length M: 14.0 mm (10.6-20.0 mm) M: 13.9 mm (9.3-18.3 mm)
D: 13.0 mm (8.1-17.7 mm) D: 13.0 mm (8.5-18.3 mm)
Number of roots 2 (86.9%) 2 (78.6%)
3 (12.5%) 1 (19%)
1 (0.55%) 3 (2.2%)
4 (0.05%) 4 (0.2%)
Number of canals M: 1 (2.37%) M: 2 (87.1%)
2 (96.59%) 1 (12.5%)
3 (0.03%) D: 1 (92.56%)
Other (1.01%) 2 (7.44%)
D: 1 (70.3%)
2 (29.56%)
Other (0.14%)
Canal configuration M: Types IV (71.3%) M: Types IV (47.8%)
II (19.9%) II (32.8%)
III (2.9%) I (12.5%)
I (2.37%) III (3.27%)
V (2.1%) V (3%)
VI (0.3%) VI (0.2%)
VII (0.09%) VII (0.1%)
VIII (0.03%) Other (0.33%)
Other (1.01%) D: Types I (92.56%)
D: Types I (70.3%) II (4.4%)
II (13%) IV (2%)
IV (10.1%) III (0.5%)
III (3.6%) V (0.5%)
V (2.7%) VI (0.04%)
VI (0.08%)
VII (0.08%)
Other (0.14%)
Accessory canals M: 45% M: 49%
D: 30% D: 34%
Apical curvature M: Distal (84%) M: Distal (60.8%)
Straight (16%) Straight (27.2%)
D: Straight (73.5%) Buccal (4%)
Distal (18%) S-shaped (8%)
Mesial (8.5%) D: Straight (57.6%)
Distal (18.4%)
Mesial (13.6%)
Buccal (4%)
S-shaped (6.4%)
Anomalies 5 canals187 1 canal196
Radix89 Fusion/gemination199
Taurodontism190 Isthmus192
Fusion/gemination191 C-shaped110
Isthmus192
3 roots193
C-shaped194
3 canals in the distal root195
Ethnic variations Radix entomolaris is most common in Asian and North Ameri-
can native populations
M, Mesial root/canal; D, distal root/canal.

Adapted from Versiani MA, Pereira MR, Pécora JD, Sousa Neto MD: Root canal anatomy of maxillary and mandibular teeth. In Versiani MA, Basrani B, Sousa Neto MD, editors: The root canal anatomy in
permanent dentition, ed 1, Switzerland, 2018, Springer International Publishing, pp 181–240.
Maxillary First Molar Mandibular First Molar

MB DB
MB P P
P
DB MB2 DB
MB1
MB
MB D D
ML
Apical Third D Apical Third
ML ML
MB
Mandibular Second Molar

Maxillary Second Molar
Frontal View Lateral View Coronal Third
Frontal View Lateral View Coronal Third
MB P DB
P
MB
DB P
MB2
MB1
Middle Third
Middle Third
M D
Apical Third
Apical Third
Three-dimensional (3D) micro–computed tomography (micro-

Three-dimensional (3D) micro–computed tomography (micro- CT) models and two-dimensional (2D) cross-sections depicting the inter-
CT) models and two-dimensional (2D) cross-sections depicting the internal and external anatomy of mandibular molars.
nal and external anatomy of maxillary molars.
1. Why is there a need for a new root canal morphology classification system? C. Sino-America (China-Mongolia, Japan-Recent, Japan-Jomon,
A. The Weine’s classification system is limited and cannot classify all Northeast Siberia, South Siberia, American Arctic-Eskimo-
types of canal configurations. Aleuts, Northwest North America-Indians, North and South
B. The Type VIII canal system in the Vertucci classification is unclear. America-Indians)
C. The Vertucci system does not include all types of canal D. Sunda-Pacific (South East Asia, Polynesia, Micronesia)
configurations. E. Sahul-Pacific (Australia, New Guinea, Melanesia)
D. All of the above are correct. 4. Which permanent teeth or roots of permanent teeth is there a high
2. Which anterior tooth in the permanent dentition has the highest likelihood of finding two or more canals?
incidence of two roots with two bifid root apices? A. Maxillary central incisor
A. Maxillary central incisor B. Maxillary first premolar
B. Maxillary lateral incisor C. Maxillary second premolar
C. Maxillary canine D. Mandibular first premolar
D. Mandibular central incisor E. Mandibular second premolar
E. Mandibular lateral incisor F. Mesiobuccal root of the maxillary first molar
F. Mandibular canine G. Palatal root of the maxillary first molar
3. Which of the following ethnic groups has the highest incidence of radix H. Mesial root of the mandibular first molar
entomolaris? I. Distal root of the of the mandibular first molar
A. Western Eurasia (Western Europe, Middle East, and North Africa) J. Mesial root of the mandibular second molar
B. Sub-Saharan Africa (West Africa, South Africa, San) K. Distal root of the mandibular second molar
Continued
5. Which of the following ethnic groups has the highest incidence of dens C. Maxillary canine
evaginatus? D. Mandibular central or lateral incisor
A. Western Eurasia (Western Europe, Middle East, and North Africa) E. Mandibular canine
B. Sub-Saharan Africa (West Africa, South Africa, San) 7. Which of the following ethnic groups has the highest incidence of
C. Sino-America (China-Mongolia, Japan-Recent, Japan-Jomon, bifurcated permanent mandibular canine root morphology?
Northeast Siberia, South Siberia, American Arctic-Eskimo-Aleuts, A. Western Eurasia (Western Europe, Middle East, and North Africa)
Northwest North America-Indians, North and South America-Indians) B. Sub-Saharan Africa (West Africa, South Africa, San)
D. Sunda-Pacific (South East Asia, Polynesia, Micronesia) C. Sino-America (China-Mongolia, Japan-Recent, Japan-Jomon,
E. Sahul-Pacific (Australia, New Guinea, Melanesia) Northeast Siberia, South Siberia, American Arctic-Eskimo-
6. Dens invaginatus is most commonly associated with which permanent Aleuts, Northwest North America-Indians, North and South
anterior tooth? America-Indians)
A. Maxillary central incisor D. Sunda-Pacific (South East Asia, Polynesia, Micronesia)
B. Maxillary lateral incisor E. Sahul-Pacific (Australia, New Guinea, Melanesia)
Influence of Root Canal Anatomy in main canal. Numerous studies have shown that instrumentation
Endodontic Procedures and irrigation are highly effective in reducing the intracanal bac-
terial populations.218-220 Clinical219,221 and in vitro studies222,223
Outcomes of nonsurgical and surgical endodontic procedures are have clearly demonstrated that preparation using an antibacterial
highly influenced by variations in canal configuration and cross- irrigating solution such as NaOCl significantly enhances disinfec-
sectional shapes and by the presence of canal irregularities and cur- tion compared with irrigation with saline or water. Most canals
vatures. Moreover, the high frequency of fins and communications instrumented and irrigated with 2.5% NaOCl have the number
between canals within the same root make it impossible for any of bacteria reduced 102 to 105 fold, which has resulted in an over-
mechanical or chemical technique to completely disinfect the root all reduction of bacterial counts of 95% to 99%.222,224 Regular
canal system. It is noteworthy to point out that some factors, such as exchange and the use of large volumes of irrigants should main-
physiologic aging, pathology, and occlusion, as well as the secondary tain the optimum antibacterial effectiveness of the NaOCl solu-
deposition of dentin, can increase the mentioned variations, making tion, compensating for the effects of concentration.222 It has been
shaping and cleaning the root canals a real challenge. Hence, the reported that the beneficial effects of using NaOCl compared with
purpose of the treatment must be toward reducing the level of con- saline are only observed after significant apical enlargement.219,221
tamination as far as possible and entombing the remaining micro- Several studies agree that supplementary irrigation methods using
organisms. Clinicians ought, therefore, to be aware of complex root laser- or ultrasonic-activated irrigation and positive-pressure
canal structures, cross-sectional dimensions, and iatrogenic altera- pulsed-delivery systems perform better than syringe irrigation in
tions of canal anatomy. In this way, it is advisable to make a careful the removal of dentin debris or soft tissue remnants from fins and
diagnostic interpretation based on angled radiographs or tomo- noninstrumented oval extensions,33-35 but the relative effective-
graphic examinations, proper access preparation, and a detailed ness of each method is still unclear.216
inspection of the pulp chamber floor. Ideally the search for root Accessory canals and dentinal tubules present similar chal-
canal orifices should be under magnification with high intensity lenges for root canal irrigation but at a different length scale.
lighting, aiming to improve the treatment outcome.22 Accessory canals (10 µm to 200 µm) are perceived to be smaller
Essentially, there are three conditions that the clinician faces than the main canal but larger than dentinal tubules (0.5 µm to
routinely when undertaking root canal treatment: teeth with vital 3.2 µm).25 Irrigant flow in accessory canals and dentinal tubules
and irreversibly inflamed pulps, teeth with necrotic pulps with is driven by the flow in the main canal and appears to be limited
or without primary apical periodontitis, and retreatment cases to a depth approximately twice their diameter, whereas diffusion
because of posttreatment apical periodontitis. In teeth with irre- dominates irrigant transport beyond that point. Therefore opti-
versible pulpitis, infection is usually restricted to the coronal parts mum irrigant refreshment in the main canal to maintain a favor-
of the canal and is easily controlled by abundant irrigation of the able concentration gradient, any increase in the temperature of the
pulp chamber with sodium hypochlorite (NaOCl) after comple- irrigants, and a longer application period could enhance particle
tion of the access cavity preparation. Then, under strict aseptic transport. Nevertheless, the importance of accessory canal and
conditions, the clinician needs to clean the canal by removing dentinal tubule cleaning for the success of root canal treatment
the inflamed vital pulp tissue as much as possible.216 In necrotic has been debated.225
untreated teeth and treated teeth referred for retreatment because Despite the optimal antibacterial effect obtained by che-
of posttreatment apical periodontitis an infection is established in momechanical preparation, clinical bacteriologic studies have
the root canal system. In these cases, in addition to cleaning the demonstrated that 30% to 60% of the previously infected root
canal from the necrotic pulp tissue or the previous filling mate- canals still have detectable levels of bacteria after instrumenta-
rial, the clinician also needs to combat infection. The successful tion.218-220,226-228 The main reasons for bacteria to persist after
treatment outcome will depend on how effective the clinician is in chemomechanical procedures is that they are resistant to treat-
achieving these goals.217 ment or they are unaffected by instruments/irrigants. Although
One of the main steps of root canal treatment involved with some microorganisms have been shown to be resistant to some
disinfection of the root canal system is chemomechanical prepara- endodontic antimicrobial agents,229 resistance both to debride-
tion. This procedure is of utmost importance for cleaning and dis- ment and to NaOCl is highly unlikely to occur. Bacteria usually
infection, because instruments and irrigants act primarily in the survive after treatment procedures not because they are more
TABLE
12.7
NUMBER OF ROOTS (%) NUMBER OF ROOT CANALS (%)

References Population Study Type Sample 1 2 3 ≥4 1 2 3 4 ≥5
Maxillary Third Molars
Barret200 USA Sectioning 32 28.1 34.4 37.5 - - - - - -
Piñeda & Kuttler17 Mexico Radiograph 292 - - - - 21.4 51.7 21.0 5.9 -
Green18 USA Sectioning 100 MB - - - - 63.0 37.0 - - -
Hession201 Australia Radiograph 12 - - - - 16.7 25.0 58.3 - -
Pécora et al.202 Brazil Clearing 50 - - - - - - 68.0 32.0 -
Guerisoli et al.203 Brazil Clearing 155 12.3 1.9 81.9 3.8a 4.5 11.6 67.8 14.2 1.9
Stropko204 USA Retrospective 25 - - - - - 20.0 60.0 20.0 -
Sidow et al.111 USA Clearing 150 15.3 32 45.3 7.4 7.4 c 3.3 57.3 27.3 4.7d
Ng et al.205 Burma Clearing 72 19.4 19.4 55.6 5.6 5.6 25.0 47.2 22.2 -
Alavi et al.206 Thailand Clearing 151 1.3 6.6 88.1 4.0 9.9 11.3 48.3 29.1 1.3
Weng et al.207 China Clearing 43 - - - - 27.9 11.6 44.2 16.3 -
Sert et al.208 Turkey Clearing 290 35.5 28.6 34.1 1.7 12.4 29.7 46.9 11.0 -
Cosic et al.209 Croatia Sectioning 56 8.9 5.4 83.9 1.8 7.1 7.1 75.0 10.8 -
Tomaszewska et al.210 Poland Micro-CT 78 38.5 - 61.5 - 23.1 15.4 46.1 15.4 -
Mandibular Third Molars
Barret200 USA Sectioning 32 15.6 71.9 12.5 - - - - - -

Piñeda & Kuttler17 Mexico Radiograph 259 - - - - - 65.8 26.4 7.8 -
Green18 USA Sectioning 100 MR - - - - 74.0 26.0 - - -
Hession201 Australia Radiograph 3 - - - - - 33.3 66.7 - -
Zakhary et al.211 Egypt Radiograph 374 11.8 82.3 5.9 - 11.8 17.6 64.7 5.9 -
Guerisoli et al.203 Brazil Clearing 114 51.8 46.4 1.8 - 12.3 69.3 18.4 - -
Sidow et al.111 USA Clearing 150 16.7 76.7 5.3 1.3 7.3e 16.7 55.3 16.7 4.0d
Gulabivala et al. Burma Clearing 58 - 100 - - 1.7 51.7 44.8 1.7 -
Gulabivala et al.212 Thailand Clearing 173 11.6 86.7 21.2 0.6 6.4 64.1 28.3 5.2 -
Sert et al.208 Turkey Clearing 370 24.9 69.5 5.4 0.3 10.8 52.7 17.3 18.6 0.5
Kuzekanani et al.213 Iran Clearing 150 21.4 72.6 5.3 0.7 10.0f 52.0 32.7 5.3 -
Cosic et al.209 Croatia Sectioning 50 56.0 44.0 - - 4.0 6.0 90.0 - -
Park et al.214 South Korea Tomography 214 41.6b 56.5 1.9 - - - - - -
MB, Mesiobuccal root; micro-CT, micro–computed tomography; MR, mesial root.

a0.6% of the sample had five roots; b3.7% of the sample had C-shaped canals;
c4.7% of the sample had C-shaped canals; d0.7% of the sample had six canals;
e4.0% of the sample had C-shaped canals; f3.3% of the sample had C-shaped canals.
Adapted from Ahmad IA, Azzeh MM, Zwiri AMA, Haija MASA, Diab MM: Root and root canal morphology of third molars in a Jordanian subpopulation, Saudi Endod J 6:113, 2016.215
TABLE
12.8
NUMBER OF ROOTS (%) ROOT CANAL CONFIGURATION (%)

Number of
Maxillary Teeth 1 2 3 4 I II III IV V VI VII VIII Other
Central 3125 99.94 0.06 0 0 99.20 0.1 0.1 0.5 0.1 0 0 0 0
incisor
Lateral incisor 3068 99.94 0.06 0 0 98.50 0.8 0.2 0.1 0.4 0 0 0 0
Canine 3148 100 0 0 0 97.0 0.8 1.2 0.2 0.7 0 0 0 0.1
1st premolar 2575 43.1 55.3 1.6 0 20.10 17.4 1.5 50.1 3.0 4.9 0.4 1.2 1.3
2nd premolar 2345 86.2 13.5 0.3 0 42.70 18.7 4.0 17.6 9.6 6.3 0.5 0.4 0.3
1st molar 8934 0.2 1.8 97.7 0.3
MB root 8934 39.10 29.3 1.6 26.0 2.0 1.4 0.1 0.1 0.4
DB root 7473 98.60 0.4 0.3 0.2 0.4 0.01 0 0 0
P root 8445 99.26 0.3 0.2 0.1 0.1 0 0 0 0.04
2nd molar 9570 10.7 14.9 73.7 0.7
MB root 9353 66.10 15.3 2.8 13.0 1.9 0.6 0.1 0.05 0.2
DB root 9570 99.60 0.2 0.07 0.1 0.03 0 0 0 0
P root 9570 99.67 0.1 0.1 0.1 0.05 0 0 0.01 0.01
Mandibular 1 2 3 4 I II III IV V VI VII VIII Other
Central 11860 100 0 0 0 86.5 2.0 8.1 1.4 2.8 0 0.1 0 0.1
incisor
Lateral 11805 99.92 0.08 0 0 79.7 2.6 11.9 1.8 3.8 0 0.1 0 0.1
incisor
Canine 10009 98.57 1.43 0 0 92.4 1.9 2.7 1.5 1.2 0 0 0 0.3
1st premolar 6043 97.5 2.5 0 0 71.3 2.3 2.8 3.5 18.7 0.5 0.1 0.1 0.7
2nd premolar 6350 98.5 1.5 0 0 84.7 0.7 0.5 0.3 13.4 0.07 0.04 0.05 0.2
1st molar 7388 0.55 86.9 12.5 0.05
Mesial root 7388 2.37 19.9 2.9 71.3 2.1 0.3 0.09 0.03 1.01
Distal root 6712 70.3 13.0 3.6 10.1 2.7 0.08 0.08 0 0.14
2nd molar 7439 19.0 78.6 2.2 0.2
Mesial root 6734 12.5 32.8 3.27 47.8 3.0 0.2 0.1 0 0.33
Distal root 7439 92.56 4.4 0.5 2.0 0.5 0.04 0 0 0

CBCT, Cone beam computed tomography; DB, distobuccal; MB, mesiobuccal; P, palatal.
Adapted from Versiani MA, Pereira MR, Pécora JD, Sousa Neto MD: Root canal anatomy of maxillary and mandibular teeth. In Versiani MA, Basrani B, Sousa Neto MD, editors. The root canal anatomy in
resistant but because they were not affected by instruments and instrumentation using reaming motions.230,231 Recesses are com-
irrigants. Bacteria remain unaffected because treatment was inad- monly left untouched at the extremities of the canal’s largest diameter
equately carried out (small instrumentation, too short of the (Fig. 12.26).232,233 In addition to harboring remnants of pulp tis-
apex, poor irrigation, etc.) or because bacteria were located in sue or bacterial biofilms, such recesses may also be packed with
difficult-to-reach anatomic areas. In fact, the latter is the main dentin chips generated and pushed therein by rotating instru-
reason for bacterial persistence even after diligent endodontic ments.32,33 Packed debris can interfere with the quality of obtura-
treatment. Canals that are flattened or oval-shaped are often not tion and, in infected root canals, can harbor bacteria to serve as a
properly cleaned and disinfected by current hand or rotary NiTi potential source of persistent infection.234
of the root and root canals. Perhaps the most important aspect
of assessing the degree of difficulty of an endodontic treatment is
to know the dental anatomy of the tooth requiring treatment. A
thorough cleaning and shaping of a canal system is accomplished
by observing and anticipating the complexity of the internal
pulpal anatomy. The Washington Study238 and others since239,240
have shown that not all teeth that received endodontic treatment
enjoyed the same degree of success. By inference, it was the realiza-
tion that all teeth in the dental arch did not have a simple, single
“hollow-tube” to the apical foramen and differed in root morphol-
ogy in many ways.
The dental literature is replete with examples of complex dental
root anatomy, and many of the cases are a result of endodontic
failure to heal because of missed, poorly filled, or unfilled canal
systems. The importance of learning both the normal and varia-
tions from the normal morphology of roots and root canals in the
human dentition cannot be overemphasized. The dental anatomy
research of root number and root shape will help the clinician in
a search for canal systems within the pulp chamber or along the
canal length.
Teeth that have a broad diameter, usually in the labiolingual or
buccolingual direction, have been shown to have a high incidence
of double or even multiple canal numbers and apical foramen out-
A lets. Multiple root canal classification systems have been proposed
over the years, each with their own advantages and shortcomings.
Standard radiographs may only give clues to the complexity of
canal systems. Even 3D radiographs like the CBCT need a high
resolution and a degree of skill in interpreting the image of a
root canal system. The clinicians who know their ability and can
anticipate a complex root canal system during instrumentation
can be more thorough in cleansing and shaping the entire root
canal space. The highest success rate and the lowest number of
failed treatments will result as a treatment outcome when dental
anatomy is taken into account.␣
Conclusions
Knowledge of both normal root and root canal anatomy is
B most critically important to perform successful endodontic
treatment. The science of dental anatomy of the human denti-
Three-dimensional (3D) micro–computed tomography (micro-
CT) models and two-dimensional (2D) cross-sections of a (A) mesial root
tion helps a dentist not only in restorative dentistry for cor-
of mandibular molar and (B) a mandibular canine showing the superim- onal anatomy, but also in endodontic therapy with root and
posed root canal system before (in green) and after (in red) preparation root canal anatomy research. A number of conclusions may
with rotary nickel-titanium (NiTi) instruments, depicting the irregularities of be drawn from reading the information in this chapter about
the root canal shape left untouched (arrows). human root canal anatomy as it relates to a proposed endodon-
tic treatment:
In summary, anatomic complexities represent physical con- -
straints that pose a serious challenge to adequate disinfection. The tury. Root anatomy and canal anatomy research specifically was
main root canal lumen and minor anatomic irregularities are usually the interest of dental anatomists for over a century, as shown by
incorporated into preparation and affected by NaOCl, but bacte- a perusal of the important early dental literature. However, its
ria and organic tissue may remain in areas not reached by instru- importance in performing root canal treatment has made this
ments and irrigants.234-236 Unaffected areas include root canal walls the province of modern endodontology.
untouched by instruments, recesses, dentinal tubules, isthmuses,
lateral canals, and apical ramifications.230,235-237 These areas are new techniques when the historical perspective is taken into
usually not affected because of the inherent physical limitations of account, with three loosely defined phases of root canal mor-
instruments and the short retention time of irrigants within the root phology research.
canal system. If bacterial biofilms remain in untouched and unaf-
fected canal areas, the treatment outcome is put at risk.217␣ or Vertucci and more lately by Ahmed et al. using the Univer-
sal Tooth Number system all have their advantages and dif-
Clinical Outcome Remarks ficulties when applied to clinical or laboratory root anatomy
research. Nonetheless, our understanding of the complexity
Diagnosis and treatment planning for endodontic therapy involves of the morphology of pulp space has expanded from the ear-
the reading of clinical radiographs to determine the morphology lier studies.
-
ber, which is continuous with the radicular root canal space in normal may occur in greater numbers in certain ethnic
anterior teeth. Posterior teeth may have a chamber floor when populations and include things like root number in maxil-
the radicular roots form in their embryonic development. lary and mandibular premolar teeth, bifurcation and double
canals in mandibular canines, dens evaginatus in premolar
in the arch, but each tooth also has its own unique morphology teeth, C-shaped, and taurodont anomalies, to name a few.
of root shape and canal number as controlled by many genetic All of these variations from the average must be recognized
factors. as possible complications before endodontic treatment is
- initiated.
ber and canal number for each tooth in the dental arch, one -
can see the relative likelihood of finding more than one canal ber of ways and may result in a high degree of difficulty, which
per root in a clinical situation. would be a reason to refer treatment to a specialist for end-
odontic treatment.
of mandibular molar teeth, is most common in Asian and -
North American native indigenous populations, and the inci- ment is to not anticipate or locate the double or multiple canal
dence may be as high as 20% in some populations. system in roots that have a wide labiolingual or buccolingual
diameter.
many other variable features of the human dentition in the
printed tables shows that the more posterior tooth is slightly to visualize the shape and dimensions of teeth in the dental
smaller and less distinctive in its dental characteristics. arch.
8. When a tooth requires endodontic therapy, which of the following C. Main canal.
statements is correct with respect to root canal morphology? D. Furcation canals.
A. There is usually one straight canal within any given root. 14. In cross-section, root canal shapes are classified as:
B. The canal is usually positioned more to the facial. A. Oval
C. Assume that each root may contain more than one canal system. B. Round
D. Canals tend to become larger with age. C. Long oval
9. The resurgence of studies of human root and canal anatomy may be D. Flattened
attributed to: E. Irregular
A. Newer laboratory and clinical radiographic techniques such as F. Regular
CBCT 15. Which of the following are consistent with a transverse anastomosis
B. Additional populations to be studied in dental schools outside of as found in some ovoid-shaped roots, which contain two or more canal
North America and Europe systems?
C. A growing interest in endodontics and realization that knowledge of A. It is also called an isthmus.
variations in dental root anatomy is the key to successful treatment B. It is a narrow, ribbon-shaped communication between two root
D. The resurrection of practitioners wanting to prove the “theory of focal canals.
infection” and the inability to seal root canals 100% C. It always contains vital tissue.
10. Krasner and Rankow proposed a series of laws to aid in determining D. It can contain necrotic debris.
the position of the pulp chamber and the location and number of canal E. It may contain biofilm.
entrances. The “law of centrality” means that the pulp chamber is 16. In the study by Schäfer and colleagues that measured the degree
centered in the tooth: of curvature of more than 1000 root canals from all groups of
A. At the midpoint of the crown teeth by using radiographs, the highest degree of curvature was
B. At the level of the cementoenamel junction found in the:
C. 1 mm occlusal to the furcation A. Mesiobuccal canal of maxillary molars
D. But it is highly variable in its vertical position B. Distobuccal canal of maxillary molars
11. Krasner and Rankow proposed a series of laws to aid in determining C. Mesial canals of mandibular molars
the position of the pulp chamber and the location and number of canal D. Distal canals of mandibular molars
entrances. The “law of color change” means that: 17. Which of the following developmental anomaly condition is
A. The walls are darker than the floor of the pulp chamber. characterized by an enlarged pulp chamber and root trunk and a
B. The walls are lighter than the floor of the pulp chamber. shortening of the roots?
C. Both the walls and floor become lighter in color with secondary A. Dens invaginatus
dentin with age. B. Dens evaginatus
12. Which of the following are routinely used for the identification of all C. Taurodontism
canal orifices during molar root canal therapy during routine access D. Radix entomolaris
opening procedure? E. C-shaped canal system
A. Good illumination 18. Which of the following root canal anatomy factors are known to affect
B. Magnification the outcome of surgical and nonsurgical endodontics?
C. CBCT imaging A. Canal irregularities
D. Specialized instruments B. Canal curvature
13. Which of the following components of the root canal system are C. The presence of fins
primarily cleansed by chemomechanical means? D. The deposition of secondary and tertiary dentin with age
A. Accessory canals.
B. Lateral canals.
ANSWERS
Answer Box 12 9. Correct answer: D. Only statement “D” is incorrect. The practitioners
1. Correct Answer: D. Both the Weine and Vertucci classification systems who are trying to discredit the safety and successfulness of current
have limitations because neither can classify all canal system configu- endodontic treatment use the century-old and faulty research methods
rations. The Vertucci classification system has sometimes been used in- and papers. The third phase of human root anatomy research uses
consistently. One example is how a three-rooted maxillary first premolar modern imaging systems and have expanded to include worldwide
with a single canal in each root is classified. Some authors classify dental schools and touch on all ethnicities.
this as Type VIII, whereas others classify the canal system in each root 10. Correct answer: B. Understanding the series of laws outlined by Krasner
(mesiobuccal, distobuccal, and palatal) as Type I canal systems. and Rankow is critical to endodontic treatment success and conversely,
2. Correct answer: F. The mandibular canine is the most common anterior avoiding iatrogenic errors that could lead to adverse treatment outcome.
tooth to have a bifurcated root. The root bifurcates into a labial and 11. Correct answer: B. Understanding the series of laws outlined by Krasner
lingual root and can have an incidence of 3% to 5%, especially in some and Rankow is critical to endodontic treatment success and conversely,
Western Eurasian populations. avoiding iatrogenic errors that could lead to adverse treatment outcome.
3. Correct answer: C. Radix entomolaris is an extra root found in a lingual 12. Correct answers: A, B and D. Although CBCT can be a valuable adjunct
position of the permanent mandibular molar. Therefore a mandibular in endodontics, it should be used selectively where indicated. The stand-
molar would have three roots (mesial, distolingual, and distobuccal) in- ard of practice and ALARA concept (As Low As Reasonably Achievable)
stead of the typical two roots (mesial and distal). This is most common do not dictate special imaging techniques in routine operations.
in Asian and North American aboriginal populations in the permanent 13. Correct answer: C. Accessibility, location, and orientation of the main
mandibular first molar. The incidence can be 20% or more in these canal in a tooth receiving endodontic therapy are the primary reasons
populations. for the importance of mechanical means in canal cleansing.
4. Correct answers: B, F, H and J. Each of these teeth or roots of teeth 14. Correct answer: A, B, C, D and E. The internal shape of the root canal
generally have a significantly high incidence of two canals. system mirrors the external shape of the root, which is variable in its
5. Correct answer: C. Dens evaginatus presents as a tubercle on the oc- morphology throughout the dentition.
clusal surface of any of the premolars and has the highest incidence in 15. Correct answers: A, B, D and E. The four answers describe a root canal
Asian and North American aboriginal populations. system transverse anastomosis. This difficult to reach region of a root
6. Correct answer: B. This infolding of enamel can be mild to severe. canal system is contaminated both in necrotic therapy and in retreat-
Oehlers classified dens invaginatus as Types 1, 2, and 3 with the most ment endodontics and thus difficult to seal effectively.
severe form being Type 3. The permanent maxillary lateral incisor is the 16. Correct answers: A and C. The greater the canal curvature, the more
tooth that is most commonly affected with this developmental anomaly. complex the endodontic treatment of that canal becomes. Also, age
7. Correct answer: A. Although the incidence of bifurcated permanent leads to narrower canal systems, which compounds the complexity.
mandibular canines is relatively low, it is highest in the Western 17. Correct answer: C. This accurately describes taurodontism. Teeth most
Eurasian ethnic group (approximately 5% to 6%) in both ancient and commonly involved are the molars and possibly premolars. As a result
modern populations. of the large volume of pulp contained in the large pulp chamber, excess
8. Correct answer: C. It is critically important to always assume that a root bleeding may be challenging to manage on performing an access open-
has more than one canal until proven otherwise. Failure to find, cleanse, ing when the pulp is highly inflamed.
instrument, and obturate the entire root canal system in any given 18. Correct answer: A, B, C and D. All of the factors listed previously
tooth will likely result in treatment failure. Although some roots and contribute to increasing the complexity of root canal treatment and the
some teeth may be more likely to be elongated in cross-section and not clinical outcome.
round, there are a few rare anomalies of double canal formation that
may not appear on a standard radiograph.
References 6. Kuttler Y: Microscopic investigation of root apexes, J Am Dent

Assoc 50(5):544–552, 1955.
1. Trope M, Elfenbein L, Tronstad L: Mandibular premolars 7. Skidmore AE, Bjorndal AM: Root canal morphology of the human
with more than one root canal in different race groups, J Endod mandibular first molar, Oral Surg Oral Med Oral Pathol 32(5):778–
12(8):343–345, 1986. 784, 1971.
2. Perrini N, Versiani MA: Historical overview of the studies on root 8. Davis SR, Brayton SM, Goldman M: The morphology of the pre-
canal anatomy. In Versiani MA, Basrani B, Sousa Neto MD, edi- pared root canal: a study utilizing injectable silicone, Oral Surg Oral
tors: The root canal anatomy in permanent dentition, ed 1, Switzer- Med Oral Pathol 34(4):642–648, 1972.
land, 2018, Springer International Publishing, pp 3–16. 9. Green D: Morphology of the pulp cavity of the permanent teeth,
3. Martins JN, Versiani MA: CBCT and micro-CT on the study of Oral Surg Oral Med Oral Pathol 8(7):743–759, 1955.
root canal anatomy. In Versiani MA, Basrani B, Sousa Neto MD, 10. Green D: A stereomicroscopic study of the root apices of 400
editors: The root canal anatomy in permanent dentition, ed 1, Swit- maxillary and mandibular anterior teeth, Oral Surg Oral Med Oral
zerland, 2018, Springer International Publishing, pp 89–180. Pathol 9(11):1224–1232, 1956.
4. Basrani B, Versiani MA: Contemporary strategies for teaching 11. Tratman EK: A comparison of the teeth of people; Indo-European
internal anatomy of teeth. In Versiani MA, Basrani B, Sousa Neto racial stock with the Mongoloid race stock, Dent Rec (London)
MD, editors: The root canal anatomy in permanent dentition, ed 1, 70(3):63–68, 1950.
Switzerland, 2018, Springer International Publishing, pp 373–390. 12. Versiani MA, Pécora JD, Sousa-Neto MD: Microcomputed tomog-
5. Ingle JI: The need for endodontic instrument standardization, Oral raphy analysis of the root canal morphology of single-rooted man-
Surg Oral Med Oral Pathol 8(11):1211–1213, 1955. dibular canines, Int Endod J 46(9):800–807, 2013.
13. Kato A, Ohno N: Construction of three-dimensional tooth model 36. Perez R, Neves AA, Belladonna FG, et al.: Impact of the needle
by micro-computed tomography and application for data sharing, insertion depth on the removal of hard-tissue debris, Int Endod J
Clin Oral Investig 13(1):43–46, 2009. 50(6):560–568, 2016.
14. Scott R, Turner II C: The anthropology of modern human teeth, 37. von Arx T: Frequency and type of canal isthmuses in first molars
Cambridge, 2000, Cambridge University Press. detected by endoscopic inspection during periradicular surgery, Int
15. Dummer PM, McGinn JH, Rees DG: The position and topogra- Endod J 38(3):160–168, 2005.
phy of the apical canal constriction and apical foramen, Int Endod 38. American Association of Endodontists: Glossary of endodontics
J 17(4):192–198, 1984. terms, ed 9, Chicago, 2016, American Association of Endodontists.
16. Weine FS, Healey HJ, Gerstein H, Evanson L: Canal configuration in 39. Ricucci D, Siqueira Jr JF: Fate of the tissue in lateral canals and
the mesiobuccal root of the maxillary first molar and its endodontic apical ramifications in response to pathologic conditions and treat-
significance, Oral Surg Oral Med Oral Pathol 28(3):419–425, 1969. ment procedures, J Endod 36(1):1–15, 2010.
17. Piñeda F, Kuttler Y: Mesiodistal and buccolingual roentgeno- 40. Vertucci FJ: Root canal anatomy of the human permanent teeth,
graphic investigation of 7,275 root canals, Oral Surg Oral Med Oral Oral Surg Oral Med Oral Pathol 58(5):589–599, 1984.
Pathol 33(1):101–110, 1972. 41. Vertucci FJ, Williams RG: Root canal anatomy of the mandibular
18. Green D: Double canals in single roots, Oral Surg Oral Med Oral first molar, J N J Dent Assoc 45(3):27–28, 1974.
Pathol 35(5):689–696, 1973. 42. Vertucci FJ, Anthony RL: A scanning electron microscopic investiga-
19. Piñeda F: Roentgenographic investigation of the mesiobuccal tion of accessory foramina in the furcation and pulp chamber floor of
root of the maxillary first molar, Oral Surg Oral Med Oral Pathol molar teeth, Oral Surg Oral Med Oral Pathol 62(3):319–326, 1986.
36(2):253–260, 1973. 43. Versiani MA, Pécora JD, Sousa-Neto MD: Update in root canal
20. Seidberg BH, Altman M, Guttuso J, Suson M: Frequency of two anatomy of permanent teeth using microcomputed tomography. In
mesiobuccal root canals in maxillary permanent first molars, J Am Basrani B, editor: Endodontic irrigation: chemical disinfection of the
Dent Assoc 87(4):852–856, 1973. root canal system, ed 1, Switzerland, 2015, Springer International
21. Vertucci F, Seelig A, Gillis R: Root canal morphology of the Publishing AG, pp 15–44.
human maxillary second premolar, Oral Surg Oral Med Oral Pathol 44. Gutierrez JH, Aguayo P: Apical foraminal openings in human
38(3):456–464, 1974. teeth. Number and location, Oral Surg Oral Med Oral Pathol Oral
22. Versiani MA, Ordinola-Zapata R: Root canal anatomy: implica- Radiol Endod 79(6):769–777, 1995.
tions in biofilm disinfection. In Chavez de Paz L, Sedgley C, Kishen 45. Versiani MA, Ahmed HM, Sousa-Neto MD, et al.: Unusual
A, editors: Root canal biofilms, ed 1, Toronto, 2015, Springer Inter- deviation of the main foramen from the root apex, Braz Dent J
national Publishing AG, pp 23–52. 27(5):589–591, 2016.
23. De Deus QD: Frequency, location, and direction of the lateral, sec- 46. Mizutani T, Ohno N, Nakamura H: Anatomical study of the root
ondary, and accessory canals, J Endod 1(11):361–366, 1975. apex in the maxillary anterior teeth, J Endod 18(7):344–347, 1992.
24. Ordinola-Zapata R, Versiani MA, Bramante CM: Root canal com- 47. Morfis A, Sylaras SN, Georgopoulou M, et al.: Study of the api-
ponents. In Versiani MA, Basrani B, Sousa Neto MD, editors: The ces of human permanent teeth with the use of a scanning electron
root canal anatomy in permanent dentition, ed 1, Switzerland, 2018, microscope, Oral Surg Oral Med Oral Pathol 77(2):172–176, 1994.
Springer International Publishing, pp 31–46. 48. Marceliano-Alves MF, Sousa-Neto MD, Fidel SR, et al.: Shaping
25. Tjäderhane L: Dentin basic structure, composition, and function. ability of single-file reciprocating and heat-treated multifile rotary
In Versiani MA, Basrani B, Sousa Neto MD, editors: The root canal systems: a micro-CT study, Int Endod J 48(12):1129–1136, 2015.
anatomy in permanent dentition, ed 1, Switzerland, 2018, Springer 49. Nagy CD, Szabó J, Szabó J: A mathematically based classifica-
International Publishing, pp 17–30. tion of root canal curvatures on natural human teeth, J Endod
26. Krasner P, Rankow HJ: Anatomy of the pulp-chamber floor, J 21(11):557–560, 1995.
Endod 30(1):5–16, 2004. 50. Weine FS: Endodontic therapy, ed 5, St. Louis, 1996, Mosby-Year-
27. Jou YT, Karabucak B, Levin J, Liu D: Endodontic working width: book, Inc.
current concepts and techniques, Dent Clin North Am 48(1):323– 51. Schneider SW: A comparison of canal preparations in straight and
335, 2004. curved root canals, Oral Surg Oral Med Oral Pathol 32(2):271–275,
28. Wu MK, R’oris A, Barkis D, Wesselink PR: Prevalence and extent 1971.
of long oval canals in the apical third, Oral Surg Oral Med Oral 52. Weine FS: Endodontic therapy, ed 3, St. Louis, 1982, Mosby.
Pathol Oral Radiol Endod 89(6):739–743, 2000. 53. Pruett JP, Clement DJ, Carnes Jr DL: Cyclic fatigue testing of nickel-
29. Weller RN, Niemczyk SP, Kim S: Incidence and position of the titanium endodontic instruments, J Endod 23(2):77–85, 1997.
canal isthmus. Part 1. Mesiobuccal root of the maxillary first molar, 54. Schäfer E, Diez C, Hoppe W, Tepel J: Roentgenographic investiga-
J Endod 21(7):380–383, 1995. tion of frequency and degree of canal curvatures in human perma-
30. Vertucci FJ: Root canal morphology and its relationship to end- nent teeth, J Endod 28(3):211–216, 2002.
odontic procedures, Endod Topics 10(1):3, 2005. 55. Peiris R: Root and canal morphology of human permanent teeth in
31. Hsu YY, Kim S: The resected root surface. The issue of canal isth- a Sri Lankan and Japanese population, Anthropol Sci 116(2):123–
muses, Dent Clin North Am 41(3):529–540, 1997. 133, 2008.
32. De-Deus G, Marins J, Silva EJ, et al.: Accumulated hard tissue 56. Gupta S, Sinha DJ, Gowhar O, et al.: Root and canal morphology of
debris produced during reciprocating and rotary nickel-titanium maxillary first premolar teeth in North Indian population using clear-
canal preparation, J Endod 41(5):676–681, 2015. ing technique: an in vitro study, J Conserv Dent 18(3):232–236, 2015.
33. Versiani MA, Alves FR, Andrade-Junior CV, et al.: Micro-CT eval- 57. Bulut DG, Kose E, Ozcan G, et al.: Evaluation of root morphology
uation of the efficacy of hard-tissue removal from the root canal and root canal configuration of premolars in the Turkish individu-
and isthmus area by positive and negative pressure irrigation sys- als using cone beam computed tomography, Eur J Dent 9(4):551–
tems, Int Endod J 49(11):1079–1087, 2016. 557, 2015.
34. Keleș A, Alcin H, Sousa-Neto MD, Versiani MA: Supplementary 58. Elnour M, Khabeer A, AlShwaimi E: Evaluation of root canal
steps for removing hard tissue debris from isthmus-containing morphology of maxillary second premolars in a Saudi Arabian sub-
canal systems, J Endod 42(11):1677–1682, 2016. population: an in vitro microcomputed tomography study, Saudi
35. Leoni GB, Versiani MA, Silva-Sousa YT, et al.: Ex vivo evalua- Dent J 28(4):162–168, 2016.
tion of four final irrigation protocols on the removal of hard-tissue 59. Ahmed HMA, Versiani MA, De-Deus G, Dummer PMH: A new
debris from the mesial root canal system of mandibular first molars, system for classifying root and root canal morphology, Int Endod J
Int Endod J 50(4):398–406, 2017. 50(8):761–770, 2017.
60. Versiani MA, Ordinola-Zapata R, Keleș A, et al.: Middle mesial 86. Carlsen O, Alexandersen V: Radix mesiolingualis and radix disto-
canals in mandibular first molars: a micro-CT study in different lingualis in a collection of permanent maxillary molars, Acta Odon-
populations, Arch Oral Biol 61(1):130–137, 2016. tol Scand 58(5):229–236, 2000.
61. Versiani MA, Martins JN, Basrani B: 3D visual glossary of termi- 87. Souza-Flamini LE, Leoni GB, Chaves JF, et al.: The radix ento-
nology in root and root canal anatomy. In Versiani MA, Basrani molaris and paramolaris: a micro-computed tomographic study of
B, Sousa Neto MD, editors: The root canal anatomy in permanent 3-rooted mandibular first molars, J Endod 40(10):1616–1621, 2014.
dentition, ed 1, Switzerland, 2018, Springer International Publish- 88. Calberson FL, De Moor RJ, Deroose CA: The radix entomo-
ing, pp 391–422. laris and paramolaris: clinical approach in endodontics, J Endod
62. Hargreaves KM, Cohen S: Cohen’s pathways of the pulp, ed 10, St. 33(1):58–63, 2007.
Louis, 2011, Mosby. 89. De Moor RJ, Deroose CA, Calberson FL: The radix entomolaris
63. Nanci A, Ten Cate AR: Ten Cate’s oral histology: development, struc- in mandibular first molars: an endodontic challenge, Int Endod J
ture, and function, ed 8, St. Louis, 2013, Elsevier. 37(11):789–799, 2004.
64. Woelfel JB, Scheid RC: Dental anatomy: its relevance to dentistry, ed 90. Carlsen O, Alexandersen V: Radix paramolaris in permanent man-
6, Philadelphia, 2002, Lippincott Williams & Wilkins. dibular molars: identification and morphology, Scan J Dent Res
65. Jafarzadeh H, Azarpazhooh A, Mayhall JT: Taurodontism: a review 99(3):189–195, 1991.
of the condition and endodontic treatment challenges, Int Endod J 91. Tratman EK: Three-rooted lower molars in man and their racial
41(5):375–388, 2008. distribution, Br Dent J 64:264–274, 1938.
66. Gardner DG, Girgis SS: Taurodontism, shovel-shaped incisors and 92. Turner 2nd CG: Three-rooted mandibular first permanent molars
the Klinefelter syndrome, Dent J 44(8):372–373, 1978. and the question of American Indian origins, Am J Phys Anthropol
67. Regezi JA, Sciubba JJ, Jordan RCK: Oral pathology: clinical patho- 34(2):229–241, 1971.
logic correlations, ed 5, St. Louis, 2008, Saunders/Elsevier. 93. Cooke 3rd HG, Cox FL: C-shaped canal configurations in man-
68. Sert S, Bayrl G: Taurodontism in six molars: a case report, J Endod dibular molars, J Am Dent Assoc 99(5):836–839, 1979.
30(8):601–602, 2004. 94. Keith A, Knowles FH: The description of teeth of palaeolithic man
69. Mjör IA: The structure of taurodont teeth, ASDC J Dent Child from Jersey, J Anat Physiol 46(pt 1):12–27, 1911.
39(6):459–463, 1972. 95. Jafarzadeh H, Wu YN: The C-shaped root canal configuration: a
70. Keith A: Problems relating to the teeth of the earlier forms of pre- review, J Endod 33(5):517–523, 2007.
historic man, Proc R Soc Med 6(Odontol Sect):103–124, 1913. 96. Melton DC, Krell KV, Fuller MW: Anatomical and histological
71. Shaw JC: Taurodont teeth in South African races, J Anat 62(Pt features of C-shaped canals in mandibular second molars, J Endod
4):476–498, 1928. 17(8):384–388, 1991.
72. Tsesis I, Shifman A, Kaufman AY: Taurodontism: an endodontic 97. Fan B, Yang J, Gutmann JL, Fan M: Root canal systems in mandibular
challenge. Report of a case, J Endod 29(5):353–355, 2003. first premolars with C-shaped root configurations. Part I: microcom-
73. Metgud S, Metgud R, Rani K: Management of a patient with a puted tomography mapping of the radicular groove and associated
taurodont, single-rooted molars associated with multiple dental root canal cross-sections, J Endod 34(11):1337–1341, 2008.
anomalies: a spiral computerized tomography evaluation, Oral Surg 98. Solomonov M, Paqué F, Fan B, et al.: The challenge of C-shaped
Oral Med Oral Pathol Oral Radiol Endod 108(2):e81–e86, 2009. canal systems: a comparative study of the self-adjusting file and Pro-
74. Hülsmann M: Dens invaginatus: aetiology, classification, preva- Taper, J Endod 38(2):209–214, 2012.
lence, diagnosis, and treatment considerations, Int Endod J 99. Cleghorn BM, Christie WH, Dong CC: Anomalous mandibular
30(2):79–90, 1997. premolars: a mandibular first premolar with three roots and a man-
75. Ridell K, Mejáre I, Matsson L: Dens invaginatus: a retrospective dibular second premolar with a C-shaped canal system, Int Endod J
study of prophylactic invagination treatment, Int J Paediatr Dent 41(11):1005–1014, 2008.
11(2):92–97, 2001. 100. Fan B, Ye W, Xie E, et al.: Three-dimensional morphological analy-
76. Rotstein I, Stabholz A, Heling I, Friedman S: Clinical consider- sis of C-shaped canals in mandibular first premolars in a Chinese
ations in the treatment of dens invaginatus, Endod Dent Traumatol population, Int Endod J 45(11):1035–1041, 2012.
3(5):249–254, 1987. 101. Gu YC, Zhang YP, Liao ZG, Fei XD: A micro-computed tomo-
77. Oehlers FA: Dens invaginatus (dilated composite odontome). I. graphic analysis of wall thickness of C-shaped canals in mandibular
Variations of the invagination process and associated anterior crown first premolars, J Endod 39(8):973–976, 2013.
forms, Oral Surg Oral Med Oral Pathol 10(11):1204–1218, 1957. 102. Bóveda C, Fajardo M, Millán B: Root canal treatment of an invagi-
78. Poyton HG, Morgan GA: Dens in dente, Dent Radiogr Photogr nated maxillary lateral incisor with a C-shaped canal, Quintessence
39(2):27–33, 1966. Int 30(10):707–711, 1999.
79. Ruprecht A, Sastry KA, Batniji S, Lambourne A: The clinical sig- 103. Manning SA: Root canal anatomy of mandibular second molars.
nificance of dental invagination, J Pedod 11(2):176–181, 1987. Part II. C-shaped canals, Int Endod J 23(1):40–45, 1990.
80. Oehlers FA: Dens invaginatus (dilated composite odontome). II. 104. Yang ZP, Yang SF, Lin YC, et al.: C-shaped root canals in mandib-
Associated posterior crown forms and pathogenesis, Oral Surg Oral ular second molars in a Chinese population, Endod Dent Traumatol
Med Oral Pathol 10(12):1302–1316, 1957. 4(4):160–163, 1988.
81. Oehlers FA, Lee KW, Lee EC: Dens evaginatus (evaginated odon- 105. Weine FS, Pasiewicz RA, Rice RT: Canal configuration of the man-
tome). Its structure and responses to external stimuli, Dent Pract dibular second molar using a clinically oriented in vitro method, J
Dent Rec 17(7):239–244, 1967. Endod 14(5):207–213, 1988.
82. Levitan ME, Himel VT: Dens evaginatus: literature review, 106. Jin GC, Lee SJ, Roh BD: Anatomical study of C-shaped canals in
pathophysiology, and comprehensive treatment regimen, J Endod mandibular second molars by analysis of computed tomography, J
32(1):1–9, 2006. Endod 32(1):10–13, 2006.
83. Kocsis G, Marcsik A, Kókai E, Kocsis K: Supernumerary occlusal cusps 107. Al-Fouzan KS: C-shaped root canals in mandibular second molars
on permanent human teeth, Acta Biol Szeged 46(1-2):71–82, 2002. in a Saudi Arabian population, Int Endod J 35(6):499–504, 2002.
84. Merrill RG: Occlusal anomalous tubercles on premolars of Alaskan 108. Haddad GY, Nehme WB, Ounsi HF: Diagnosis, classification, and
Eskimos and Indians, Oral Surg Oral Med Oral Pathol 17(4):484– frequency of C-shaped canals in mandibular second molars in the
496, 1964. Lebanese population, J Endod 25(4):268–271, 1999.
85. Versiani MA, Pécora JD, Sousa-Neto MD: Root and root canal 109. Cheung LH, Cheung GS: Evaluation of a rotary instrumentation
morphology of four-rooted maxillary second molars: a micro-com- method for C-shaped canals with micro-computed tomography, J
puted tomography study, J Endod 38(7):977–982, 2012. Endod 34(10):1233–1238, 2008.
110. Fan B, Cheung GS, Fan M, et al.: C-shaped canal system in 134. Naseri M, Safi Y, Akbarzadeh Baghban A, et al.: Survey of anatomy
J Endod and root canal morphology of maxillary first molars regarding age
30(12):899–903, 2004. and gender in an Iranian population using cone-beam computed
111. Sidow SJ, West LA, Liewehr FR, Loushine RJ: Root canal mor- tomography, Iran Endod J 11(4):289–303, 2016.
phology of human maxillary and mandibular third molars, J Endod 135. Ratanajirasut R, Panichuttra A, Panmekiate S: A cone-beam com-
26(11):675–678, 2000. puted tomographic study of root and canal morphology of max-
112. Gu Y, Zhang Y, Liao Z: Root and canal morphology of mandibular illary first and second permanent molars in a Thai population, J
first premolars with radicular grooves, Arch Oral Biol 58(11):1609– Endod 44(1):56–61, 2018.
1617, 2013. 136. Versiani MA, Pereira MR, Pécora JD, Sousa Neto MD: Root canal
113. Ordinola-Zapata R, Bramante CM, Villas-Boas MH, et al.: Mor- anatomy of maxillary and mandibular teeth. In Versiani MA, Bas-
phologic micro–computed tomography analysis of mandibular pre- rani B, Sousa Neto MD, editors: The root canal anatomy in per-
molars with three root canals, J Endod 39(9):1130–1135, 2013. manent dentition, ed 1, Switzerland, 2018, Springer International
114. Rice RT, Gilbert Jr BO: An unusual canal configuration in a man- Publishing, pp 181–240.
dibular first molar, J Endod 13(10):513–515, 1987. 137. Fogel HM, Peikoff MD, Christie WH: Canal configuration in the
115. Martins JN, Quaresma S, Quaresma MC, Frisbie-Teel J: C-shaped mesiobuccal root of the maxillary first molar: a clinical study, J
maxillary permanent first molar: a case report and literature review, Endod 20(3):135–137, 1994.
J Endod 39(12):1649–1653, 2013. 138. Ross IF, Evanchik PA: Root fusion in molars: incidence and sex
116. De Moor RJ: C-shaped root canal configuration in maxillary first linkage, J Periodontol 52(11):663–667, 1981.
molars, Int Endod J 35(2):200–208, 2002. 139. Sert S, Bayirli GS: Evaluation of the root canal configurations of
117. Yang ZP, Yang SF, Lee G: The root and root canal anatomy of the mandibular and maxillary permanent teeth by gender in the
maxillary molars in a Chinese population, Endod Dent Traumatol Turkish population, J Endod 30(6):391–398, 2004.
4(5):215–218, 1988. 140. Nelson SJ, Ash Jr MM: Wheeler’s dental anatomy, physiology, and
118. Ordinola-Zapata R, Monteiro Bramante C, Gagliardi Minotti P, occlusion, ed 9, St. Louis, 2010, Saunders Elsevier.
et al.: Micro-CT evaluation of C-shaped mandibular first premolars 141. González-Plata RR, González-Plata EW: Conventional and sur-
in a Brazilian subpopulation, Int Endod J 48(8):807–813, 2015. gical treatment of a two-rooted maxillary central incisor, J Endod
119. Yu X, Guo B, Li KZ, et al.: Cone-beam computed tomography 29(6):422–424, 2003.
study of root and canal morphology of mandibular premolars in a 142. Lambruschini GM, Camps J: A two-rooted maxillary central inci-
western Chinese population, BMC Med Imaging 12(18), 2012. sor with a normal clinical crown, J Endod 19(2):95–96, 1993.
120. Lu TY, Yang SF, Pai SF: Complicated root canal morphology of 143. Lin WC, Yang SF, Pai SF: Nonsurgical endodontic treatment of a
mandibular first premolar in a Chinese population using the cross two-rooted maxillary central incisor, J Endod 32(5):478–481, 2006.
section method, J Endod 32(10):932–936, 2006. 144. Gondim Jr E, Setzer F, Zingg P, Karabucak B: A maxillary central
121. Fan B, Min Y, Lu G, Yang J, et al.: Negotiation of C-shaped canal sys- incisor with three root canals: a case report, J Endod 35(10):1445–
tems in mandibular second molars, J Endod 35(7):1003–1008, 2009. 1447, 2009.
122. Camargo AJ, Arita ES, Watanabe PC: Fusion or gemination? An 145. Mangani F, Ruddle CJ: Endodontic treatment of a “very particu-
unusual mandibular second molar, Int J Surg Case Rep 21:73–77, 2016. lar” maxillary central incisor, J Endod 20(11):560–561, 1994.
123. Shoor H, Sujir N, Mutalik S, Pai KM: Hypercementosis: a rare find- 146. Pécora JD, da Cruz Filho AM: Study of the incidence of radicular
ing in a patient with systemic lupus erythematosus, BMJ Case Rep grooves in maxillary incisors, Braz Dent J 3(1):11–16, 1992.
pii:bcr2013202370, 2014. https://doi.org/10.1136/bcr-2013-202370. 147. Libfeld H, Stabholz A, Friedman S: Endodontic therapy of bilat-
124. Tomes CS: A manual of dental anatomy, human and comparative, ed erally geminated permanent maxillary central incisors, J Endod
8, New York, 1923, MacMillan Co. 12(5):214–216, 1986.
125. Cleghorn B, Christie W, Dong C: The root and root canal mor- 148. Pécora JD, Santana SV
phology of the human mandibular first premolar: a literature case report, Braz Dent J 2(2):151–153, 1992.
review, J Endod 33(5):509–516, 2007. 149. Peix-Sánchez M, Miñana-Laliga R: A case of unusual anatomy: a
126. Johnstone M, Parashos P: Endodontics and the ageing patient, Aust maxillary lateral incisor with three canals, Int Endod J 32(3):236–
Dent J 60(Suppl 1):20–27, 2015. 240, 1999.
127. Gani OA, Boiero CF, Correa C, et al.: Morphological changes 150. Kottoor J, Murugesan R, Albuquerque DV: A maxillary lateral
related to age in mesial root canals of permanent mandibular first incisor with four root canals, Int Endod J 45(4):393–397, 2012.
molars, Acta Odontol Latinoam 27(3):105–109, 2014. 151. Fried IL, Winter AA: Diagnosis and treatment of a two-rooted
128. Thomas RP, Moule AJ, Bryant R: Root canal morphology of maxillary lateral incisor, Periodontal Case Rep 6(2):40–44, 1984.
maxillary permanent first molar teeth at various ages, Int Endod J 152. Wong M: Treatment considerations in a geminated maxillary lat-
26(5):257–267, 1993. eral incisor, J Endod 17(4):179–181, 1991.
129. Lee JH, Kim KD, Lee JK, et al.: Mesiobuccal root canal anatomy of 153. Pécora JD, Saquy PC, de Souza JE, Sousa-Neto MD: Endodontic
Korean maxillary first and second molars by cone-beam computed treatment of a maxillary lateral incisor presenting dens invaginatus
tomography, Oral Surg Oral Med Oral Pathol Oral Radiol Endod and transposition to the region of the canine - case report, Braz
111(6):785–791, 2011. Dent J 2(1):5–8, 1991.
130. Kayaoglu G, Peker I, Gumusok M, et al.: Root and canal symme- 154. Mupparapu M, Singer SR, Goodchild JH: Dens evaginatus and
try in the mandibular anterior teeth of patients attending a dental dens invaginatus in a maxillary lateral incisor: report of a rare
clinic: CBCT study, Braz Oral Res 29(1):1–7, 2015. occurrence and review of literature, Aust Dent J 49(4):201–203,
131. Zhengyan Y, Keke L, Fei W, et al.: Cone-beam computed tomog- 2004.
raphy study of the root and canal morphology of mandibular per- 155. Leoni GB, Versiani MA, Pécora JD, Damião de Sousa-Neto MD:
manent anterior teeth in a Chongqing population, Ther Clin Risk Micro–computed tomographic analysis of the root canal morphol-
Manag 12:19–25, 2016. ogy of mandibular incisors, J Endod 40(5):710–716, 2013.
132. Martins J, Ordinola-Zapata R, Marques D, et al.: Differences in 156. Sachdeva GS, Malhotra D, Sachdeva LT, et al.: Endodontic man-
root canal system configuration in human permanent teeth within agement of mandibular central incisor fused to a supernumer-
different age groups, Int Endod J 51(8):931–941, 2018. ary tooth associated with a talon cusp: a case report, Int Endod J
133. Falcão CA, Albuquerque VC, Amorim NL, et al.: Frequency of the 45(6):590–596, 2012.
mesiopalatal canal in upper first permanent molars viewed through 157. Khabbaz MG, Konstantaki MN, Sykaras SN: Dens invaginatus in
computed tomography, Acta Odontol Latinoam 29(1):54–59, 2016. a mandibular lateral incisor, Int Endod J 28(6):303–305, 1995.
158. Loushine RJ, Jurcak JJ, Jeffalone DM: A two-rooted mandibular 183. Peikoff MD, Christie WH, Fogel HM: The maxillary second
incisor, J Endod 19(5):250–251, 1993. molar: variations in the number of roots and canals, Int Endod J
159. Barkhordar RA, Nguyen NT: Maxillary canine with two roots, J 29(6):365–369, 1996.
Endod 11(5):224–227, 1985. 184. Kottoor J, Hemamalathi S, Sudha R, Velmurugan N: Maxillary
160. Sousa Neto MD, Zuccolotto WG, Saquy PC, et al.: Treatment second molar with 5 roots and 5 canals evaluated using cone beam
of dens invaginatus in a maxillary canine case report, Braz Dent J computerized tomography: a case report, Oral Surg Oral Med Oral
2(2):147–150, 1992. Pathol Oral Radiol Endod 109(2):e162–e165, 2010.
161. Versiani MA, Pécora JD, Sousa-Neto MD: The anatomy of two- 185. Koenen DJ, Pahncke D: Gemination or fusion: use of a CT scan to
rooted mandibular canines determined using micro-computed assist in diagnosis and endodontic treatment of a maxillary second
tomography, Int Endod J 44(7):682–687, 2011. molar - a case report, ENDO 2(2):145–151, 2008.
162. Orguneser A, Kartal N: Three canals and two foramina in a man- 186. Radwan A, Kim SG: Treatment of a hypertaurodontic maxillary
dibular canine, J Endod 24(6):444–445, 1998. second molar in a patient with 10 taurodonts: a case report, J Endod
163. Soares JA, Leonardo RT: Root canal treatment of three-rooted 40(1):140–144, 2013.
maxillary first and second premolars – a case report, Int Endod J 187. Friedman S, Moshonov J, Stabholz A: Five root canals in a man-
36(10):705, 2003. dibular first molar, Endod Dent Traumatol 2(5):226–228, 1986.
164. Lammertyn PA, Rodrigo SB, Brunotto M, Crosa M: Furcation 188. Ryan JL, Bowles WR, Baisden MK, McClanahan SB: Mandibular
groove of maxillary first premolar, thickness, and dentin structures, first molar with six separate canals, J Endod 37(6):878–880, 2011.
J Endod 35(6):814–817, 2009. 189. Reeh ES: Seven canals in a lower first molar, J Endod 24(7):497–
165. Nahmias Y, Rampado ME: Root-canal treatment of a trifid crown 499, 1998.
premolar, Int Endod J 35(4):390–394, 2002. 190. Ashwin R, Arathi R: Taurodontism of deciduous and permanent
166. Çolak H, Aylikçi BU, Keklik H: Dens evaginatus on maxillary first molars: report of two cases, J Indian Soc Pedod Prev Dent 24(1):42–
premolar: report of a rare clinical case, J Nat Sci Biol Med 3(2):192– 44, 2006.
194, 2012. 191. Tsesis I, Steinbock N, Rosenberg E, Kaufman AY: Endodontic
167. Rotstein I, Stabholz A, Friedman S: Endodontic therapy for dens treatment of developmental anomalies in posterior teeth: treat-
invaginatus in a maxillary second premolar, Oral Surg Oral Med ment of geminated/fused teeth – report of two cases, Int Endod J
Oral Pathol 63(2):237–240, 1987. 36(5):372, 2003.
168. Vaghela DJ, Sinha AA: Endodontic management of four rooted 192. Fan B, Pan Y, Gao Y, et al.: Three-dimensional morphologic analy-
mandibular first premolar, J Conserv Dent 16(1):87–89, 2013. sis of isthmuses in the mesial roots of mandibular molars, J Endod
169. Stecker S, DiAngelis AJ: Dens evaginatus: a diagnostic and treat- 36(11):1866–1869, 2010.
ment challenge, J Am Dent Assoc 133(2):190–193, 2002. 193. Schäfer E, Breuer D, Janzen S: The prevalence of three-rooted man-
170. Tavano SM, de Sousa SM, Bramante CM: Dens invaginatus in first dibular permanent first molars in a German population, J Endod
mandibular premolar, Endod Dent Traumatol 10(1):27–29, 1994. 35(2):202–205, 2009.
171. Aryanpour S, Bercy P, Van Nieuwenhuysen JP: Endodontic and 194. Bolger WL, Schindler WG: A mandibular first molar with a
periodontal treatments of a geminated mandibular first premolar, C-shaped root configuration, J Endod 14(10):515–519, 1988.
Int Endod J 35(2):209–214, 2002. 195. Filpo-Perez C, Bramante CM, Villas-Boas MH, et al.: Micro-
172. De Moor RJ, Calberson FL: Root canal treatment in a mandibular computed tomographic analysis of the root canal morphology of
second premolar with three root canals, J Endod 31(4):310–313, the distal root of mandibular first molar, J Endod 41(2):231–236,
2005. 2015.
173. Farmakis ET: Four-rooted mandibular second premolar, Aust 196. Fava LR, Weinfeld I, Fabri FP, Pais CR: Four second molars with
Endod J 34(3):126–128, 2008. single roots and single canals in the same patient, Int Endod J
174. Demiryürek EÖ, Gönülol N, Bulucu B: Endodontic treatment of a 33(3):138–142, 2000.
taurodontic premolar with five canals, Aust Endod J 39(2):81–84, 2013. 197. Chokshi S, Mehta J, Chokshi P, Vaidya R: Morphological varia-
175. Goswami M, Chandra S, Chandra S, Singh S: Mandibular premo- tions in the root canal system of mandibular second molar: a case
lar with two roots, J Endod 23(3):187, 1997. series, Endodontology 25:135, 2013.
176. Koh ET, Ford TR, Kariyawasam SP, et al.: Prophylactic treat- 198. Beatty RG, Krell K: Mandibular molars with five canals: report of
ment of dens evaginatus using mineral trioxide aggregate, J Endod two cases, J Am Dent Assoc 114(6):802–804, 1987.
27(8):540–542, 2001. 199. Ballal S, Sachdeva G, Kandaswamy D: Endodontic management
177. Muthukumar RS, Arunkumar S, Sadasiva K: Bilateral fusion of of a fused mandibular second molar and paramolar with the aid of
mandibular second premolar and supernumerary tooth: a rare case spiral computed tomography: a case report, J Endod 33(10):1247–
report, J Oral Maxillofac Pathol 16(1):128–130, 2012. 1251, 2007.
178. Gopikrishna V, Bhargavi N, Kandaswamy D: Endodontic man- 200. Barrett MT: The internal anatomy of the teeth with special refer-
agement of a maxillary first molar with a single root and a single ence to the pulp with its branches, Dent Cosmos 67:581, 1925.
canal diagnosed with the aid of spiral CT: a case report, J Endod 201. Hession RW: Endodontic morphology. II. A radiographic analysis,
32(7):687–691, 2006. Oral Surg Oral Med Oral Pathol 44(4):610–620, 1977.
179. Beatty RG: A five-canal maxillary first molar, J Endod 10(4):156– 202. Pécora JD, Woelfel JB, Sousa Neto MD, Issa EP: Morphologic
157, 1984. study of the maxillary molars. Part II: Internal anatomy, Braz Dent
180. Albuquerque DV, Kottoor J, Dham S, et al.: Endodontic man- J 3(1):53–57, 1992.
agement of maxillary permanent first molar with 6 root canals: 3 203. Guerisoli DM, de Souza RA, de Sousa Neto MD, Silva RG, Pécora
case reports, Oral Surg Oral Med Oral Pathol Oral Radiol Endod JD: External and internal anatomy of third molars, Braz Dent J
110(4):e79–e83, 2010. 9(2):91–94, 1998.
181. Kottoor J, Velmurugan N, Sudha R, Hemamalathi S: Maxillary 204. Stropko JJ: Canal morphology of maxillary molars: clinical obser-
first molar with seven root canals diagnosed with cone-beam com- vations of canal configurations, J Endod 25(6):446–450, 1999.
puted tomography scanning: a case report, J Endod 36(5):915–921, 205. Ng YL, Aung TH, Alavi A, Gulabivala K: Root and canal mor-
2010. phology of Burmese maxillary molars, Int Endod J 34(6):620–630,
182. Kottoor J, Velmurugan N, Surendran S: Endodontic management 2001.
of a maxillary first molar with eight root canal systems evaluated 206. Alavi AM, Opasanon A, Ng YL, Gulabivala K: Root and canal
using cone-beam computed tomography scanning: a case report, J morphology of Thai maxillary molars, Int Endod J 35(5):478–485,
Endod 37(5):715–719, 2011. 2002.
207. Weng XL, Yu SB, Zhao SL, et al.: Root canal morphology of per- hypochlorite or 2% chlorhexidine as the main irrigant: a random-
manent maxillary teeth in the Han nationality in Chinese Guan- ized clinical study, J Endod 42(6):943–947, 2016.
zhong area: a new modified root canal staining technique, J Endod 225. Boutsioukis C: Internal tooth anatomy and root canal irrigation.
35(5):651–656, 2009. In Versiani MA, Basrani B, Sousa Neto MD, editors: The root canal
208. Sert S, Sahinkesen G, Topçu FT, et al.: Root canal configurations anatomy in permanent dentition, ed 1, Switzerland, 2018, Springer
of third molar teeth. A comparison with first and second molars in International Publishing, pp 303–322.
the Turkish population, Aust Endod J 37(3):109–117, 2011. 226. Paquette L, Legner M, Fillery ED, Friedman S: Antibacterial effi-
209. Cosić J, Galić N, Vodanović M, et al.: An in vitro morphologi- cacy of chlorhexidine gluconate intracanal medication in vivo, J
cal investigation of the endodontic spaces of third molars, Coll Endod 33(7):788–795, 2007.
Antropol 37(2):437–442, 2013. 227. Siqueira Jr JF, Guimarães-Pinto T, Rôças IN: Effects of chemome-
210. Tomaszewska IM, Leszczyński B, Wróbel A, et al.: A micro-com- chanical preparation with 2.5% sodium hypochlorite and intraca-
puted tomographic (micro-CT) analysis of the root canal morphol- nal medication with calcium hydroxide on cultivable bacteria in
ogy of maxillary third molar teeth, Ann Anat 215:83–92, 2018. infected root canals, J Endod 33(7):800–805, 2007.
211. Zakhary SY, Fahim OM, Gorgy AA: Morphologic characteristics 228. Siqueira Jr JF, Rôças IN, Paiva SS, et al.: Bacteriologic investigation
of lower third molar as related to successful endodontic therapy, of the effects of sodium hypochlorite and chlorhexidine during the
Egypt Dent J 34(4):323–337, 1988. endodontic treatment of teeth with apical periodontitis, Oral Surg
212. Gulabivala K, Opasanon A, Ng YL, Alavi A: Root and canal mor- Oral Med Oral Pathol Oral Radiol Endod 104(1):122–130, 2007.
phology of Thai mandibular molars, Int Endod J 35(1):56–62, 2002. 229. Sirén EK, Haapasalo MP, Waltimo TM, Ørstavik D: In vitro anti-
213. Kuzekanani M, Haghani J, Nosrati H: Root and canal morphology bacterial effect of calcium hydroxide combined with chlorhexidine
of mandibular third molars in an Iranian population, J Dent Res or iodine potassium iodide on Enterococcus faecalis, Eur J Oral Sci
Dent Clin Dent Prospects 6(3):85–88, 2012. 112(4):326–331, 2004.
214. Park JB, Kim N, Park S, et al.: Evaluation of root anatomy of perma- 230. Paqué F, Balmer M, Attin T, Peters OA: Preparation of oval-shaped
nent mandibular premolars and molars in a Korean population with root canals in mandibular molars using nickel-titanium rotary
cone-beam computed tomography, Eur J Dent 7(1):94–101, 2013. instruments: a micro-computed tomography study, J Endod 36(4):
215. Ahmad IA, Azzeh MM, Zwiri AMA, et al.: Root and root canal 703–707, 2010.
morphology of third molars in a Jordanian subpopulation, Saudi 231. De-Deus G, Barino B, Zamolyi RQ, et al.: Suboptimal debride-
Endod J 6(3):113–121, 2016. ment quality produced by the single-file F2 ProTaper technique in
216. Siqueira Jr JF: Roças IN, Ricucci D: Internal tooth anatomy and oval-shaped canals, J Endod 36(11):1897–1900, 2010.
root canal instrumentation. In Versiani MA, Basrani B, Sousa 232. Versiani MA, Leoni GB, Steier L, et al.: Micro-computed tomog-
Neto MD, editors: The root canal anatomy in permanent dentition, raphy study of oval-shaped canals prepared with the Self-adjusting
ed 1, Switzerland, 2018, Springer International Publishing, pp File, Reciproc, WaveOne, and ProTaper universal systems, J Endod
277–302. 39(8):1060–1066, 2013.
217. Siqueira Jr JF, Roças IN: Clinical implications and microbiol- 233. Versiani MA, Pécora JD, de Sousa-Neto MD: Flat-oval root canal
ogy of bacterial persistence after treatment procedures, J Endod preparation with self-adjusting file instrument: a micro-computed
34(11):1291–1301, 2008. tomography study, J Endod 37(7):1002–1007, 2011.
218. McGurkin-Smith R, Trope M, Caplan D, Sigurdsson A: Reduc- 234. Ricucci D, Siqueira Jr JF, Bate AL, Pitt Ford TR: Histologic investiga-
tion of intracanal bacteria using GT rotary instrumentation, tion of root canal-treated teeth with apical periodontitis: a retrospec-
5.25% NaOCl, EDTA, and Ca(OH)2, J Endod 31(5):359–363, tive study from twenty-four patients, J Endod 35(4):493–502, 2009.
2005. 235. Nair PN, Henry S, Cano V, Vera J: Microbial status of apical root
219. Shuping GB, Ørstavik D, Sigurdsson A, Trope M: Reduction of canal system of human mandibular first molars with primary apical
intracanal bacteria using nickel-titanium rotary instrumentation periodontitis after “one-visit” endodontic treatment, Oral Surg Oral
and various medications, J Endod 26(12):751–755, 2000. Med Oral Pathol Oral Radiol Endod 99(2):231–252, 2005.
220. Siqueira Jr JF, Paiva SS, Rôças IN: Reduction in the cultivable bac- 236. Vera J, Siqueira Jr JF, Ricucci D, et al.: One- versus two-visit end-
terial populations in infected root canals by a chlorhexidine-based odontic treatment of teeth with apical periodontitis: a histobacterio-
antimicrobial protocol, J Endod 33(5):541–547, 2007. logic study, J Endod 38(8):1040–1052, 2012.
221. Rodrigues RCV, Zandi H, Kristoffersen AK, et al.: Influence of 237. Siqueira Jr JF, Alves FR, Versiani MA, et al.: Correlative bacte-
the apical preparation size and the irrigant type on bacterial reduc- riologic and micro-computed tomographic analysis of mandibular
tion in root canal–treated teeth with apical periodontitis, J Endod molar mesial canals prepared by self-adjusting file, Reciproc, and
43(7):1058–1063, 2017. twisted file systems, J Endod 39(8):1044–1050, 2013.
222. Siqueira Jr JF, Rôças IN, Favieri A, Lima KC: Chemomechani- 238. Ingle JI, Taintor JF: The Washington study. In Ingle JI, Taintor JF,
cal reduction of the bacterial population in the root canal after editors: Endodontics, ed 3, Philadelphia, 1985, Lea & Febiger, pp
instrumentation and irrigation with 1%, 2.5%, and 5.25% sodium 27–53.
hypochlorite, J Endod 26(6):330–334, 2000. 239. Seltzer S, Bender IB, Turkenkopf S: Factors affecting successful
223. Siqueira Jr JF, Rôças IN, Santos SR, et al.: Efficacy of instrumenta- repair after root canal therapy, J Am Dent Assoc 67:651–652, 1963.
tion techniques and irrigation regimens in reducing the bacterial 240. Crump MC: Differential diagnosis in endodontic failure, Dent Clin
population within root canals, J Endod 28(3):181–184, 2002. North Am 23(4):617–635, 1979.
224. Rôças IN, Provenzano JC, Neves MA, Siqueira Jr JF: Disinfect- 241. Perrini N: Storia anatomica del sistema dei canali radicolari, Milan,
ing effects of rotary instrumentation with either 2.5% sodium 2010, Società Italiana di Endodonzia.
13
Isolation, Endodontic
Access, and Length
Determination
FABRICIO B. TEIXEIRA, ANNE E. WILLIAMSON, AND
SHAHROKH SHABAHANG
CHAPTER OUTLINE
Rubber Dam Isolation, 265 Errors in Access, 281
Access Openings, 269 Length Determination, 281
␣Access Openings and Canal Location*, 274
LEARNING OBJECTIVES
After reading this chapter the student should be able to: 5. Identify major objectives of endodontic access preparation,
1. Describe the rationale for rubber dam isolation during including importance of dentin preservation.
endodontic procedures. 6. Relate reasons and indications for removing caries or restora-
2. Describe techniques for application of the clamp and rubber tions before access.
dam. 7. Describe the technical procedure, materials used, and sequence
3. Recognize situations in which special isolation approaches are to properly access all teeth.
necessary and identify isolation techniques for unusual situa- 8. Demonstrate the step-by-step technique for obtaining esti-
tions. mated and correct working lengths.
4. Identify patients who should be considered for referral. 9. Describe the practice and accuracy of electronic apex locators.
10. Illustrate the portions of the tooth that must be removed to
attain access to the canals.
Chapters 14 and 15 address the technical aspects of nonsurgical because juries are considered competent to determine negligence.
root canal treatment. Areas presented include isolation, access, Failure to use a rubber dam indicates that the clinician does not
length determination, cleaning and shaping, and obturation. A understand the need to protect the patient from aspiration or
number of instruments and techniques are advocated for treat- swallowing instruments, the protection afforded the dental staff
ment procedures. These chapters introduce concepts and prin- from contaminated aerosols, the microbial nature of the disease
ciples that are important for successful treatment. These building process, and the decreased success rate for treatment when strict
blocks are based on the best available evidence and provide a basis asepsis is not used.
for incorporating more complex and alternative techniques. Evidence exists that many general dentists unnecessarily place
themselves at risk by not using the rubber dam when performing
endodontic procedures.2 Although the use of the rubber dam in
Rubber Dam Isolation the United States is considered the standard of care, recent studies
have shown that is not universal among general dentists. A survey
Application conducted in 2013 reported that only 44% of general dentists
Application of the rubber dam for isolation during endodontic who perform root canal therapy (RCT) use rubber dam isolation.
treatment has many distinct advantages and is mandatory for legal Moreover, 15% reported that they do not use a rubber dam for any
considerations.1 Expert testimony is not required in cases involv- of the RCTs that they provide.2 Considering that the use of rub-
ing patients who swallowed or aspirated instruments or materials, ber dam significantly increases the tooth survival rates after initial
265
266 C HA P T E R 1 3 Isolation, Endodontic Access, and Length Determination
RCT, its constant usage will improve the infection control―and tooth structure remains. Plastic clamps are manufactured and
in consequence the outcome―of endodontic treatment.3 have the advantage of being radiolucent. This radiolucency
The rubber dam provides protection for the patient and creates is an advantage in difficult cases in which the pulp chamber
an aseptic environment; it enhances visibility, retracts tissues, and and canal cannot be located. When using a plastic clamp, the
makes treatment more efficient. Soft tissues are protected from rubber dam can remain in place. The plastic clamps are less
laceration by rotary instruments, chemical agents, and medica- likely than metal ones to damage tooth structure or existing
ments. Irrigating solutions are confined to the operating field. restorations.12
Most important, rubber dam isolation protects the patient from
swallowing or aspirating instruments and materials (Fig. 13.1).4 Types
An additional advantage is that the dentist and auxiliary employees Different styles and shapes of rubber dam clamps are available for
are also protected.5-7 The risk from aerosols is minimized,8,9 and specific situations. The following selection is recommended: (1) for
the dam provides a barrier against the patient’s saliva and oral bac- anterior teeth: Ivory No. 9 or 212; for premolars: No. 0 and 2; and
teria. Application of the rubber dam may also reduce the potential for molars: No. 14, 14A, 56, and 205. Clamps that will manage
for transmission of systemic diseases, such as acquired immunode- most isolation situations during root canal treatment are shown
ficiency syndrome (AIDS), hepatitis, and tuberculosis.5,9 in Fig. 13.3. Winged clamps permit the application of the rubber
The rubber dam is manufactured from latex; however, nonlatex dam as a single unit during single-tooth isolation (Fig. 13.4).13␣
rubber dam material is available for patients with latex allergy and
is used exclusively in many institutions (Fig. 13.2).10 The rubber Universal Clamp Designs
dam can be obtained in a variety of colors that provide contrast Two designs (see Fig. 13.3), the “butterfly” Ivory No. 9 and the
to the tooth. The thickness also varies (light, medium, heavy, and Ivory No. 56, are suitable for most isolations. The butterfly design
extra heavy). A medium-weight dam is recommended because a (No. 9) has small beaks, is deep reaching, and can be applied to
lightweight dam is easily torn during the application process. Also, most anterior and premolar teeth. The No. 56 clamp can isolate
the medium material fits better at the gingival margin and pro- most molars.
vides good retraction. With teeth that are smaller, reduced by crown preparation, or
The design of the rubber dam frames also varies. For endodon- abnormally shaped, a clamp with smaller radius beaks (No. 0, 9,
tics, plastic frames are recommended; they are radiolucent and do or 14) is necessary. Small-radius beaks can be positioned farther
not require complete removal during exposure of interim images, apically on the root, which stretches the dam cervically in the
such as the working length and master cone radiographs and digi- interproximal space.
tal images (Video 13.1).␣
Additional Designs
Clamps that may be most useful when little coronal tooth struc-
Rubber Dam Retainers ture remains have beaks that are inclined apically. These are termed
Rubber dam clamps fit the various tooth groups. During rou- deep-reaching clamps. Clamps with serrated edges are also avail-
tine treatment, metal clamps are adequate; however, they may able for cases involving minimal coronal structure. These clamps
damage tooth structure11 or existing restorations. Some have should not be placed on porcelain surfaces because damage may
serrated edges to enhance retention when minimal coronal occur.11
A B
Fig. 13.1 A, A file (arrow) that a patient swallowed during endodontic treatment. B, A bur that a patient
also swallowed due to the lack of proper protection with rubber dam.
CHAPTER 13 Isolation, Endodontic Access, and Length Determination 267
C B
Fig. 13.2 A and B, Disposable rubber dam systems; C, OptiDam, a three-dimensional rubber dam.
A B
Fig. 13.3 A, The retainers in the bottom left (No. 212 and 9) are designed for anterior teeth but are useful
for premolars. The two clamps in the bottom right (No. 56 and 14) are for molars and anterior teeth. The
upper left clamps (No. 0 and 2) are for premolars. No. W14A and 14 are deeper reaching than the No. 56.
B, Clamp No. 205 can be used for most of the molars.
A B
Fig. 13.4 A, Placement of the rubber dam as a single unit requires the use of a winged clamp. A hole is
punched in the rubber dam and then stretched over the wings of the appropriate clamp. B, The rubber
dam is attached to a plastic radiolucent frame, and the rubber dam forceps is then used to carry the unit
to the tooth.
A B
C D
Fig. 13.5 A, The first molar shows extensive caries on the distal extending to the crestal bone. B, A full-
thickness, mucoperiosteal flap and osseous reduction are performed after caries excavation and preparation for
a provisional crown; then, 3 to 4 mm of tooth structure coronal to the osseous crest restores the biologic width.
C, Root canal treatment and placement of the crown. D, The definitive restoration.
For stability, the clamp selected must have four-point contact root canal treatment have large restorations, caries, or mini-
between the tooth and beaks. Failure to have a stable clamp may mal remaining tooth structure that may present complications
result in damage to the gingival attachment and coronal struc- during isolation and access. Adequate isolation requires that
ture,11,14 or the clamp may be dislodged. Clamps may also be caries, defective restorations, and restorations with leaking
modified by grinding to adapt to unusual situations.15 margins be removed before treatment. Removal of all exist-
Placement of the rubber dam as a single unit is fast and efficient. ing restorations has been advocated to improve the ability to
Once in place, the dam is flossed through the contacts, and the assess restorability, pathogenesis of disease, and prognosis.24
facial and lingual portions of the dam are flipped under the wings. Once the treatment plan has been finalized, it may be neces-
Identification of the tooth requiring treatment is usually rou- sary to perform ancillary procedures to allow for placement of the
tine. However, if no caries or restorations are present, the operator rubber dam.16,17␣
may clamp the wrong tooth. This error can be avoided by marking
the tooth before rubber dam application or by beginning the access Isolation of Teeth with Inadequate Coronal
after placement of a throat pack without the rubber dam in place.␣ Structure
Ligation, the use of deep-reaching clamps, bonding, or building
Preparation for Rubber Dam Placement up before access are the major methods of isolating teeth without
Before treatment is initiated, the degree of difficulty in obtain- adequate coronal tooth structure. Surgical management may also
ing adequate isolation must be assessed. Often, teeth requiring be required (Fig. 13.5).
In the case of inability to obtain appropriate isolation, the applicable in most cases. A traditional dam and frame can be
patient should be referred to an endodontic specialist. used, or proprietary disposable systems are available (see Fig. 13.2;
Video 13.2). The steps in this process are as follows:
Ligation 1. The dam is placed on the frame so that it is stretched tightly
Inadequate coronal structure is not always the cause of lack of across the top and bottom but has slack horizontally in the
retention. In young patients the tooth may not have erupted suf- middle.
ficiently to make the cervical area available for clamp retention. In 2. A hole is punched in the dam, and then the clamp wings are
these cases, ligation with floss or the use of interproximal rubber attached to the dam.
Wedjets is indicated (see Fig. 13.15, D). Another approach is mul- 3. The dam, frame, and clamp are placed as a unit to engage the
tiple tooth isolation (see Fig. 13.2, C, OptiDam 3D rubber dam).␣ tooth near the gingival margin.
4. The dam is released apically off the clamp wings to allow it
Deep-Reaching Clamps to constrict around the tooth neck. The dam is then flossed
When the loss of tooth structure extends below the gingival tis- through the contacts.␣
sues but there is adequate structure above the crestal bone, a deep-
reaching clamp is indicated. It may be necessary to use a caulking Placement of a Clamp, Followed by the Dam and Then the
material or resin around the clamp to provide an adequate seal Frame
(Fig. 13.6). Another option is the use of an anterior retainer Placement of a clamp followed by the dam and frame is seldom
regardless of the tooth type.␣ used but may be necessary when an unobstructed view is required
while the clamp is positioned. The clamp is first placed on the
Bonding tooth and secured. The rubber dam is then stretched over the
When there is missing tooth structure, including the natural clamp and the frame affixed (Video 13.3).5␣
height of contour, retention can be increased by bonding resin on
the facial and lingual surfaces of the remaining tooth structure.18 Placement of the Rubber Dam and Frame and Then the
The clamp is placed apical to the resin undercut. After treatment Clamp
the resin is easily removed. This technique is preferred over the The preferred method for applying a butterfly clamp that does not
more invasive technique of cutting horizontal grooves in the facial have wings (No. 212) is to place the dam and frame and then the
and lingual surfaces for the prongs of the clamp.␣ clamp. improved visibility is possible when the hole is stretched
over the tooth and gingiva first by the operator or dental assis-
Replacement of Coronal Structure tant, and the clamp is then placed. The No. 212 clamp has narrow
beaks and is often used in situations in which wing clamps are
Temporary Restorations unstable or cannot be retained.␣
When there is missing tooth structure but adequate retention,
missing structure can be restored with reinforced intermediate Rubber Dam Leakage
restorative material (IRM) containing zinc oxide–eugenol, glass
ionomers, or resins. These materials provide an adequate coro- Several proprietary products are available for placement around
nal seal and are stable until the definitive restoration is placed. the rubber dam at the tooth–dam interface should leakage occur
Bonded materials provide a better seal with improved strength and (see Fig. 13.6). These are caulklike materials, putty, or light-cured
esthetics.␣ resins; they are easily applied and removed after treatment and
are especially useful for isolation of an abutment for a fixed par-
Band Placement tial denture or for a tooth that is undergoing active orthodontic
Placement of orthodontic bands may be indicated in cases treatment.
of cracked or fractured teeth to provide protection and sup- The material can be placed on the gingival tissues at the
port until a definitive restoration can be placed. The bands dam–tooth interface after isolation. The caulking and putty
are available in various sizes and are appropriately contoured. materials adhere to wet surfaces, although the putty has a stiffer
A band can be cemented, and the missing tooth structure consistency.␣
replaced with IRM (see Fig. 13.39). During the placement
procedure, it is important to protect the canals and pulp Disinfection of the Operating Field
chamber.␣
Various methods and techniques are used to disinfect the tooth,
Provisional Crowns clamp, and surrounding rubber dam after placement. These dis-
Placement of temporary crowns is an option; however, they infectants include alcohol, quaternary ammonium compounds,
reduce visibility, result in the loss of anatomic landmarks, and sodium hypochlorite, organic iodine, mercuric salts, chlorhexi-
may change the orientation for access and canal location. Often dine, and hydrogen peroxide. An effective technique is as follows:
temporary crowns are displaced during treatment by the rubber (1) plaque is removed by rubber cup and pumice; (2) the rubber
dam clamp. In general, when provisional crowns are placed, they dam is placed; (3) the tooth surface, clamp, and surrounding rub-
should be removed before endodontic treatment to provide the ber dam are scrubbed with 30% hydrogen peroxide; and (4) the
correct orientation and maintain the remaining tooth structure.␣ surfaces are swabbed with 5% tincture of iodine or with sodium
hypochlorite.19␣
Rubber Dam Placement
Placement as a Unit
Access Openings
Placement of the rubber dam, clamp, and frame as a unit is Endodontic access openings are based on the anatomy and mor-
preferred (see Fig. 13.4). This method is most efficient and is phology of each individual tooth group. In general, the pulp
A B
C D E F
G H I
J K L M
Fig. 13.6 A, Caulking and putty materials are available to prevent leakage after rubber dam application.
B, Preoperative radiograph and C, demonstration of lack of isolation with dental floss. D, Application of the
caulk. E, The sealed dam. F, Postoperative radiograph. G, OpalDam. H, I, Two teeth sealed with OpalDam
after light curing. J, LC Block-Out. K, Before the sealing. L, Placing the Block-Out under the microscope
(yellow filter to avoid the material setting). M, Final seal after light curing.
number of root canals dictates the final design of the access prepa- cusp-to-roof distance. Dystrophic calcifications related to caries,
ration. The internal anatomy is projected onto the external sur- restorations, attrition abrasion, and erosion also can occur. In gen-
face. Internal pulp chamber morphology varies with the patient’s eral, the pulp chamber is located at the cementoenamel junction
age and secondary or tertiary dentin deposition. In anterior teeth (CEJ).22,23 In young teeth, the pulp horns are at approximately
and premolars with a single root, calcification occurs in a coronal the level of the height of contour.
to apical direction with the chamber receding. In posterior teeth The major objectives of the access openings include (1)
with bifurcations and trifurcations, secondary dentin is deposited removal of the chamber roof and all coronal pulp tissue, (2)
preferentially on the floor of the chamber, decreasing the cervi- locating all canals, (3) unimpeded straight-line access of the
cal to apical dimension of the chamber.20,21 The mesiodistal and instruments in the canals to the apical one third or the first
buccolingual dimensions remain relatively the same, as does the curve (if present), and (4) conservation of tooth structure.
Before initiating treatment, the clinician should assess the exist- outline form might be made more triangular to facilitate canal
ing coronal structure; restorations present; tooth angulation in location.
the arch; and the position, size, depth, and shape of the pulp Caries removal is essential for several reasons. First, removing
chamber. A parallel preoperative radiograph or digital image is caries permits the development of an aseptic environment before
essential. Additional angled radiographs or digital images may entering the pulp chamber and radicular space. Second, it allows
aid the identification of additional canals and roots. Bitewing assessment of restorability before treatment. Third, caries removal
radiographs and digital images offer the most accurate and provides sound tooth structure so that an adequate provisional res-
distortion-free information on chamber anatomy in posterior toration can be placed. Unsupported tooth structure is removed to
teeth. Recent advances in cone beam computed tomography ensure a coronal seal during and after treatment so that the reference
(CBCT) imaging allow three-dimensional (3D) viewing of the point for length determination is not lost should fracture occur.
pulp chamber and radicular space.25,26 Conservation of tooth Cleaning the periphery involves preventing materials and objects
structure is important for subsequent restorative treatment and from entering the chamber and canal space. A common error is
the long-term prognosis.27 Maintaining adequate structure in entering the pulp chamber before the coronal structure or restor-
the cervical region is assured by not extending the access prepa- ative materials have been adequately prepared. As a result, these
ration beyond the natural external chamber walls. The distance materials enter the canal space and may block the apical portion
from the surface of the clinical crown to the peripheral vertical of the canal.␣
wall of the pulp chamber is the same throughout the circumfer-
ence of the tooth at the level of the CEJ, and the orifices of the Canal Morphologies
root canals are located at the angles in the floor–wall junction
(Video 13.4).28,29 Five major canal morphologies have been identified (Fig. 13.7).34
They include round, ribbon or figure eight, ovoid, bowling pin,
kidney bean, and C-shape. With the exception of the round
General Principles morphologic shape, each presents unique problems for adequate
A broad discussion about the preservation of dentin during cleaning and shaping.␣
the endodontic procedures, including the conventional access,
has been subjected to debate in the literature.27 The traditional General Considerations
endodontic access underscores the concept of straight-line prepa-
ration to improve the mechanical débridement of root canals and In difficult cases the access can be prepared without the rubber
to minimize procedural errors. However, the excessive removal dam in place. This preparation allows visualization of the tooth
of tooth structure has been associated with the increased risk of shape, orientation, and position in the dental arch. When the
fracture and loss of the tooth as consequences. Lately, investiga- canal or chamber is located, the rubber dam is applied. Caution:
tors have associated the survivability of the endodontically treated Until the rubber dam is in place, broaches and files cannot be used
tooth with conservative approaches such as contracted endodontic (see Fig. 13.1).
cavities.30 Even though this concept has been questioned and not Care must be taken to prevent tooth structure or restorative
completely proved to be the predictable treatment method,31-33 materials from entering the radicular portion of the root if addi-
we deem that dentin preservation must be taken in consider- tional expansion of the access is necessary after the chamber is
ation in all procedures to increase the long-term survival rate of exposed. When an access is to be enlarged or restorative materi-
endodontically treated teeth. als removed after chamber exposure, the radicular space must be
Contemplating the debate on preservation of tooth struc- protected. The canal orifice and chamber floor can be blocked by
ture and the lack of a comprehensive opinion of the straight- placing gutta-percha temporary stopping. The material is heated
line access significance, the general principles for endodontic and then compacted with a plugger. The temporary stopping is
access remain (1) outline form, (2) convenience form, (3) caries removed with heat (preferred) or solvents after completion of the
removal, and (4) cleaning the periphery of the preparation to access preparation.
ensure it is free of any debris or objects that could fall into the Before beginning the access, the clinician should assess the
canals upon access. preoperative images to determine the degree of case difficulty. At
Outline form is the recommended shape for access preparation this stage the estimated depth of access is calculated. This calcu-
of a normal tooth with radiographic evidence of a pulp chamber lation is a measurement from the incisal edge of anterior teeth
and canal space. The outline form ensures the correct shape and and the occlusal surface of posterior teeth to the coronal portion
location and provides straight-line access to the apical portion of of the pulp chamber. Calculated in millimeters, this information
the canal or to the first curvature. The access preparation must is then transferred to the access bur and provides information on
remove tooth structure that would impede the cleaning and shap- the depth necessary to expose the pulp. If the estimated depth
ing of the canal or canals. The outline form is a projection of the of access is reached and the pulp has not been encountered, the
internal tooth anatomy onto the external root structure. The form access depth and orientation must be reevaluated. A parallel
can change with time. As an example, in anterior teeth with mesial image exposed with the rubber dam removed helps determine
and distal pulp horns, the access is triangular. In older individu- the depth and orientation so that perforations and unnecessary
als with chamber calcification, the pulp horns are absent, so the removal of tooth structure can be avoided (see Fig. 13.33).
access is ovoid. The estimated depth of access for anterior teeth is similar in
Convenience form allows modification of the ideal outline form different tooth groups.35 The maxillary central and lateral incisors
to facilitate unstrained instrument placement and manipulation. average 5.5 mm for the central incisor and 5 mm for the lateral inci-
As an example, the use of nickel–titanium rotary instruments sor. The mandibular central and lateral incisors average 4.5 mm for
requires straight-line access. An access might be modified to per- the central incisor and 5 mm for the lateral incisor. The maxillary
mit placement and manipulation of the nickel–titanium instru- canine averages 5.5 mm, and the mandibular canine, with its longer
ments. Another example is a premolar exhibiting three roots. The clinical crown, averages 6 mm. In maxillary furcated premolars, the
A B C
D E
Fig. 13.7 Common canal morphologies. A, Round. B, Ribbon shaped (hourglass). C, Ovoid. D, Bowling
pin. E, Kidney bean shaped. F, C-shaped.
average distance from the buccal cusp tip to the roof of the chamber or pathfinding instrument (0.06, 0.08, or 0.10 stainless steel file) is
is 7 mm.35 For maxillary molars, the distance is 6 mm, and for the used to explore the canal and determine canal patency close to the api-
mandibular molars, it is 6.5 mm. With an average pulp chamber cal foramen. Care should be exercised during this process to avoid forc-
height of 2 mm, the access depth for most molars should not extend ing tissue apically, which might result in canal blockage (Fig. 13.11).
beyond 8 mm (the floor of the chamber).23 This procedure is performed in the presence of irrigant or lubricant.
Access openings are best accomplished using fissure burs in the Removal of restorative materials during access is often indicated,
high-speed handpiece. A number of special burs are also available with the knowledge that after treatment a new restoration will be
for access. No single bur type is superior. For the clinician with placed. Removal enhances visibility and may reveal undetected canals,
knowledge of anatomy and morphology and the appropriate clini- caries, or coronal fractures. When difficulties occur with calcifications
cal skills and judgment, bur selection is a personal choice (Figs. or extensive restorations, the operator may become disoriented. The
13.8 and 13.9). Regardless of the high-speed bur chosen, the bur discovery of one canal can serve as a reference in locating the remain-
is placed in the chamber and removed while rotating. High-speed ing canals. A file can be inserted and an angled image exposed to
burs are not used in the canals. Failure to follow these principles reveal which canal has been located.
can result in breakage (Fig. 13.10). It is important not to violate marginal ridges during access
Visualization of the internal anatomy is enhanced during access by preparation in any of the tooth groups.
using a fiberoptic handpiece and microscopy.36 Illumination is the key. Complex restorations, such as crowns and fixed partial dentures,
A sharp endodontic explorer is used to detect the canal orifice or to may have changed the coronal landmarks used in canal location. A
aggressively dislodge calcifications. When a canal is located, a small file tipped tooth might be “uprighted” or a rotated tooth “realigned.” Loss
Fig. 13.8 Examples of access burs. Left to right, No. 4 round carbide, No. 557 carbide, Great White,
Beaver bur, Transmetal, Multipurpose bur, Endo Z bur, and Endo Access bur.
Fig. 13.9 Muller discovery Access burs.
A B
Fig. 13.10 A, Fractured fissure bur and working length file bypassing the obstruction. B, After the bur was
removed with files and ultrasonics.
of orientation can result in incorrect identification of a canal, and ␣Access Openings and Canal Location*
searching for the other canals in the wrong direction results in excessive
removal of tooth structure, perforation, or failure to locate and débride Maxillary Central and Lateral Incisors
all canals. The maxillary central incisor has one root and one canal.41 In young
Access through crowns with extensive foundations may make vis- individuals, the prominent pulp horns require a triangular outline form
ibility difficult. Class V restorations may have induced coronal calci- to ensure that tissue and obturation materials, which otherwise might
fication or could have been placed directly into the pulp space or the cause coronal discoloration, are removed (Fig. 13.13). Although the
canals. In some instances, it may be best to remove restorative materi- canal is centered in the root at the CEJ and when the tooth is viewed
als that interfere with visibility before initiating root canal treatment. from a mesial to distal orientation, it is evident that the crown is not
A modification of the armamentarium for teeth restored directly in line with the long axis of the root (Fig. 13.14). For this rea-
with crowns has been advocated for all-ceramic crowns. The son, the establishment of the outline form and initial penetration into
initial outline and penetration through ceramic (porcelain) enamel are made with the bur perpendicular to the lingual surface of
restorative material are made with a round diamond bur in the the tooth. This outline form is made in the middle third of the lingual
high-speed handpiece with water coolant. After penetration surface (Figs. 13.15 and Figs. 13.16). After penetration to the depth
into dentin, a fissure bur is used. In teeth with porcelain-fused- of 2 to 3 mm, the bur is reoriented to coincide with the long axis and
to-metal restorations, a metal cutting bur is recommended. lingual orientation of the root.
When possible, the access should remain in metal to reduce the After penetration to a depth of 2 to 3 mm, the bur is reoriented
potential for fracture in the porcelain. Evidence indicates that to coincide with the long axis and lingual orientation of the root.
with a water coolant and careful instrumentation, diamond and This reorientation reduces the risk of a lateral perforation through the
carbide burs are equally effective.37 The access is restored with facial surface. An additional common error is failure to remove the
amalgam after the root canal treatment. With the introduction lingual shelf (see Fig. 13.15, C), which results in inadequate access
of all-ceramic and zirconia crowns, specialized burs have been to the entire canal. The canal is located by using a sharp endodon-
fabricated to facilitate access through these very hard materials. tic explorer. When calcification has occurred, long-shanked burs in
In summary, aids in canal location include a knowledge of pulp a slow-speed handpiece can be used (see Figs. 13.12 and 13.24, D).
anatomy and morphology; parallel straight-on and angled radio- These burs move the head of the handpiece away from the tooth and
graphs or digital images; a sharp endodontic explorer; interim enhance the ability to see exactly where the bur is placed in the tooth.
radiographs or digital images; long-shanked, slow-speed burs Access for the maxillary lateral incisor is similar to that for the
(Fig. 13.12); ultrasonic instruments for troughing; dye staining; central incisor. A triangular access is indicated in young patients
irrigation; transillumination; and enhanced vision with loupes or with pulp horns (Fig. 13.17); as the pulp horns recede, the outline
microscopy.38 Additional aids include CBCT imaging.25,26 form becomes ovoid (Fig. 13.18).
Dens invaginatus (or dens en dente) is a common developmental
defect in the maxillary lateral incisor that results in pulp necrosis.40-42
Study Questions Additionally, a lingual groove may be found in maxillary lateral inci-
1. Avoidance of rubber dam isolation can place patients and clinicians at sors, as evidenced by a narrow probing defect. These developmental
unnecessary risk. defects complicate treatment and affect the prognosis (Video 13.5).␣
a. True
b. False
2. Rubber dam isolation serves the following purpose:
Maxillary Canines
a. Protects patient from instruments The maxillary canines have one canal in a single root. In general,
b. Provides a more aseptic field of work pulp horns are absent, so the outline form is ovoid in the middle
c. Enhances visibility third of the lingual surface (Figs. 13.19 and 13.20). As attrition
d. Retracts tissues
occurs, the chamber appears to move more incisally because of the
e. All of the above
3. If adequate tooth structure is not remaining for clamp placement, which loss of structure. In cross-section, the pulp is wide in a faciolingual
of the following is not acceptable? direction compared with the mesiodistal dimension (Video 13.6).␣
a. Rubber dam placement may be avoided.
b. The tooth may require placement of a buildup to enhance remaining Maxillary Premolars
structure.
c. The tooth may require crown lengthening procedure. The maxillary first and second premolars have a similar coronal
d. Patient may need to be referred to a specialist. structure; therefore the outline form is similar for these two teeth.
e. A deep-reaching clamp may be required. It is centered in the crown and has an ovoid shape in the faciolin-
4. What is the best time to assess difficulties and challenges in tooth gual direction (Figs. 13.21 and 13.22). An important anatomic
isolation and placement of a rubber dam? consideration with these teeth is the mesial concavity at the CEJ.
a. Before initiation of treatment
In this area, a lateral perforation is likely to occur. When two
b. At the time of placement of the clamp
c. After access preparation canals are present, the canal orifices are located under the buccal
d. After caries removal and lingual cusp tips, equidistant from a line drawn through the
5. Which of the following is correct with respect to access preparation? center of the chamber in a mesial to distal direction. The cross-
a. Endodontic access openings are based on the anatomy and sectional morphology shows a kidney bean– or ribbon-shaped
morphology of each tooth. configuration. In rare instances when three canals are present, the
b. The pulp number of root canals dictates the final design. outline form is triangular, with the base to the facial and the apex
c. Typically, the internal anatomy is projected onto the external surface. toward the lingual (Videos 13.7 and 13.8).␣
d. Age may affect the internal anatomy of the pulp chamber.
e. All of the above.
*See Appendix, Pulpal Anatomy and Access Preparations, for color illustrations
showing the size, shape, and location of the pulp space in each tooth.
A B
Fig. 13.11 A, Maxillary first molar shows extensive mesial caries. B, Histologic section of pulp tissue from
the palatal canal reveals extensive calcification. Early canal exploration should be done with small files to
avoid forcing the tissue and calcification apically and blocking the canal.
Fig. 13.12 Mueller burs have a round cutting head attached to a long shank. The long shank is not
designed to drill deep into the root, but rather to extend the head of the slow-speed handpiece away from
the tooth and permit better visibility.
D M
Fig. 13.13 A triangular outline form for access of the maxillary central incisor.
mesiobuccal canal and is in line with the buccal groove. The lin-
Maxillary Molars gual or palatal canal orifice generally exhibits the largest orifice and
The maxillary first and second molars have similar access outline lies slightly distal to the mesiolingual cusp tip. The mesiobuccal
forms. The outline form is triangular and located in the mesial half root is very broad in a buccolingual direction; thus a small second
of the tooth, with the base to the facial and the apex toward the canal is common.43-47 The mesiolingual canal orifice (commonly
lingual (Figs. 13.23 and 13.24). The transverse or oblique ridge referred to as the MB2 canal) is located 1 to 3 mm lingual to the
is left mostly intact. The external references for canal location main mesiobuccal canal (MB1 canal) and is slightly mesial to a
serve as a guide in developing the outline form. The mesiobuccal line drawn from the mesiobuccal to the lingual or palatal canal.
canal orifice lies slightly distal to the mesiobuccal cusp tip. The The initial movement of the canal from the chamber is often
distobuccal canal orifice lies distal and slightly lingual to the main not toward the apex but laterally toward the mesial (Fig. 13.25).
Fig. 13.14 Note the lingual inclination of the root in relation to the crown. In addition, the pattern of calci-
fication occurs from the coronal portion of the pulp apically.
A B
C D
Fig. 13.15 A maxillary left central incisor showing pulp necrosis. A, A large pulp space with pulp horns
that requires a triangular access outline. B, The lingual surface after removal of the orthodontic retaining
wire. Note that tooth #9 is slightly discolored. C, The initial triangular access form exposing the chamber.
Note that the lingual shelf has not been removed to expose the lingual wall. D, Removal of the lingual shelf
and completed access.
B C
D
Fig. 13.16 Crown-root fracture. A, Initial presentation demonstrating fragment separation. B, The lingual
surface with the segment removed. C, Preoperative radiograph. D, The extent of the fracture subgingivally
requires a unique approach to isolation. Note that a premolar clamp is placed on the gingival tissues for
isolation.
Removal of the coronal dentin (cornice) in this area permits expo-

sure of the canal as it begins to move apically and facilitates nego-
tiation (Figs. 13.26 and 13.27; also see Figs. 13.24 and 13.25).47
The operating microscope is a valuable aid (Video 13.9).36,38,39␣
D M
Mandibular Central and Lateral Incisors
Fig. 13.17 Triangular outline form of the maxillary lateral incisor.
The mandibular incisors are narrow in the mesiodistal dimension
and broad faciolingually. There may be one canal with an ovoid or
a ribbon-shaped configuration; often two canals are present. When
there are two canals, the facial canal is easier to locate and is generally
straighter than the lingual canal, which is often shielded by a lingual
B C D
Fig. 13.18 A, Lateral incisor with a receded pulp chamber. B, Initial ovoid outline form is initiated. C,
Coronal calcification is indicated by the color change. D, Completed access.
outline form is established into dentin with the bur perpendicular

to the lingual surface. At a depth of 2 to 3 mm, the bur is reoriented
along the long axis of the root. Because the percentage of teeth with
two canals is reported to be 25% to 40%,48,49 the lingual surface
of the chamber and canal must be diligently explored with a small,
D M precurved stainless steel file. A Gates Glidden drill or orifice shaper
is used on the lingual to remove the dentin bulge.
In cases of attrition, the access moves toward the incisal surface.
Fig. 13.19 Outline form for the maxillary canine. With the use of nickel–titanium rotary and reciprocating instru-
ments, straight-line access is imperative. A more incisal approach
bulge. Because the tooth is often tipped facially, the lingual canal is on the lingual or facial surface is justified.50 A modification of the
difficult to locate; perforations primarily occur on the facial surface access for the incisors is a facial approach.51 This approach pro-
(Video 13.10). vides better visibility and can be used when there is crowding or
The narrow mesiodistal dimension of these teeth makes access when the canal is receded below the CEJ (Video 13.11).␣
and canal location difficult. In young patients with mesiodistal pulp
horns, the outline form is triangular with the base incisally and the
apex gingivally. As the pulp recedes over time and the pulp horns
Mandibular Canines
disappear, the shape becomes more ovoid. The access is positioned The mandibular canines usually have a long, slender crown in
in the middle third of the lingual surface (Figs. 13.28 and 13.29). comparison with the maxillary canine, which is shorter and wider
Because of the small size of these teeth and the presence of mesio- in a mesiodistal direction. The tooth may have one or two roots.
distal concavities, access must be precisely positioned. The initial The root is broad in a faciolingual dimension and therefore may
A C
F
Fig. 13.20 A, The apex is obscured by the screws placed during a maxillary surgical advancement. B,
Lingual surface. C, Initial access outline into dentin. D, Access is finalized. E, Apex locator (arrow). F,
Working length.
contain two canals.49 The outline form is ovoid and positioned in

the middle third of the crown on the lingual surface (Figs. 13.30
Mandibular Premolars
and 13.31). On access opening into the chamber, the lingual sur- The mandibular premolars appear to be easy to treat, but the anat-
face should be explored for the presence of a lingual canal. As omy may be complex. One, two, or three roots are possible, and
attrition occurs, the access must be more incisal, and in severe canals often divide deep within the root in these complex mor-
cases it may include the incisal edge of the tooth (Video 13.12).␣ phologic configurations.49,52 The crown of the first premolar has
a prominent buccal cusp and a vestigial lingual cusp. In addition,

there is a lingual constriction. Mesiodistal projections reveal that
the chamber and canal orifice are positioned buccally. The access
is therefore ovoid in a buccolingual dimension and positioned
buccal to the central groove (Figs. 13.32 and 13.33). It extends
B just short of the buccal cusp tip. The mandibular second premolar
has a prominent buccal cusp, but the lingual cusp can be more
prominent than with the first premolar. There is also a lingual
constriction, so the outline form is ovoid from buccal to lingual
D M and positioned centrally (Fig. 13.34; Video 13.13).␣
Mandibular Molars
The mandibular molars are similar in anatomic configuration;
however, there are subtle differences. The most common man-
L dibular first molar configuration is two canals in the mesial root,
Fig. 13.21 Ovoid outline form for the maxillary premolars. although three have been reported,53 and one canal in the distal
root. A second canal is present in the distal root in 30% to 35% of
B C D
Fig. 13.22 A, Note the obstructed view of the apical region. B, Maxillary right second premolar. C, The
initial outline form prepared into dentin. D, The chamber and canals are accessed.
Excessive Removal of Tooth Structure

The excessive removal of tooth structure has direct consequences
and unlike inadequate preparation is irreversible and cannot be
corrected. A minimum consequence is weakening of the tooth
and subsequent coronal fracture. Evidence indicates that appro-
D M
priate access and strategic removal of tooth structure that does
not involve the marginal ridges do not significantly weaken the
remaining coronal structure.56 The marginal ridges provide the
faciolingual strength to the crown57; access openings do not
require removal of tooth structure in this area.58
Fig. 13.23 Triangular outline form for access of the maxillary molar.
The ultimate result of removing excessive tooth structure is
perforation. Perforations in single-rooted teeth are located on the
lateral surface. In multirooted teeth, perforations may be lateral or
cases (Fig. 13.35).53,55 The roots often have a kidney bean shape in furcal (see Chapter 18).␣
cross section with the concavity in the furcal region. The most com-
mon configuration for the mandibular second molar is two canals
in the mesial root and one canal in the distal root. The incidence of Length Determination
four canals is low (Video 13.14).54
The coronal reference points for canal location in the man-
Radiographic Evaluation
dibular molar roots are influenced by the position of the crown The working length is defined as the distance from a predetermined
on the root and by the lingual tipping of these teeth in the arch coronal reference point (usually the incisal edge in anterior teeth
(Fig. 13.36). The mesiobuccal canal orifice is located slightly dis- and a cusp tip in posterior teeth) to the point where the cleaning
tal to the mesiobuccal cusp tip. The mesiolingual canal orifice is and shaping and obturation should terminate. The reference point
located in the area of the central groove area and slightly distal must be stable so that fracture does not occur between visits. Unsup-
compared with the mesiobuccal canal. The distal canal is located ported cusps that are weakened by caries or restorations should be
near the intersection of the buccal, lingual, and central grooves. reduced. The point of termination is empirical and based on ana-
When a distobuccal canal is present, the orifice can be found tomic studies; it should be 1 mm from the radiographic apex.59,60
buccal to the main distal canal and often is slightly more mesial. This distance accounts for the deviation of the foramen from the
The mandibular first molar may even have a distinct separate apex, and the distance from the major diameter of the foramen to
extra distal root. Because of these anatomic relationships, the the area where a dentinal matrix can be established apically.
access outline form is rectangular or trapezoidal and positioned Before access, an estimated working length is calculated either by
in the mesiobuccal portion of the crown (Fig. 13.37). An addi- measuring the total length of the tooth on the diagnostic parallel radio-
tional variation in mandibular molars is the presence of a middle graph or digital image or with the use of an electronic apex locater.
mesial canal (Fig. 13.38). Violation of the apex may result in inoculation of the periapical tissues
During access preparation, the cervical bulge that overlies with necrotic tissue, debris, and bacteria61 and can lead to extrusion of
the canal orifices of the mesiobuccal and mesiolingual canals is materials during obturation62,63 and a less favorable prognosis.64
removed (Fig. 13.39), permitting straight-line access to the first After access preparation, a small file is used to explore the canal
curve or apical portion of the root by reducing the emergence and establish patency to the estimated working length. The largest
profile. This technique also enhances entry into the canals.␣ file to bind is then inserted to this estimated length; a file that is loose
in the canal may be displaced during film exposure or forced beyond
the apex if the patient bites down inadvertently. Millimeter markings
Errors in Access on the file shaft or rubber stops on the instrument shaft are used for
Inadequate Preparation length control. A sterile millimeter ruler or measuring device can be
used to adjust the stops on the file. To ensure accurate measurement
Errors in access preparations are varied (Fig. 13.40). A com- and length control during canal preparation, the stop must physically
mon error is inadequate preparation, which has several sig- contact the coronal reference point. To obtain an accurate measure-
nificant consequences. Direct effects are decreased access and ment, the minimum size of the working length should be a No. 20
visibility, which prevent the clinician from locating the canals. file. With files smaller than No. 20, it is difficult to interpret the loca-
The ability to remove the coronal pulp tissue and subsequent tion of the file tip on the working length film or digital image. In mul-
obturation materials is limited, and straight-line access can- tirooted teeth, files are placed in all canals before the image is made.
not be achieved. Inadequate straight-line access can indirectly Angled films or digital images are necessary to separate super-
lead to errors during the cleaning and shaping. When files are imposed files and structures (Fig. 13.41),65 to provide an effi-
deflected by coronal interferences, procedural errors, such as cient method of determining the working length, and to reduce
loss of working length, apical transportation, ledging, and api- radiation to the patient. It is imperative that the rubber dam be
cal perforation, are likely in curved canals. A No. 25 file or left in place during working length determination to ensure an
above has a straightening force that overcomes the confining aseptic environment and to protect the patient from swallowing
resistance of the dentin wall. The file cuts on the outer surface or aspirating instruments. The film/digital sensor can be held
apical to the curvature and the inner wall coronal to the curve. with a hemostat or a positioning device (Fig. 13.42).
Adequate straight-line access decreases the canal curvature and A modified paralleling technique is used to position the film/
reduces the coronal interferences, allowing the instrument to digital sensor and the cone; this has been shown to be superior to
work more freely in the canal.55␣ the bisecting-angle technique.66,67 With the modified paralleling
A B
C D
E F
Fig. 13.24 A, Maxillary left first molar. Note the calcification in the chamber. B, The outline form estab-
lished and dentin removed apically in layers. C, Exposure of the pulp horns. D, Use of a Mueller bur to
completely unroof the chamber. Note the visibility and ability for precise removal of dentin. E, The com-
pleted access. The mesiobuccal canal is evident under the mesiobuccal cusp tip, the distobuccal canal
is found opposite the buccal groove and slightly lingual to the main mesiobuccal canal, and the palatal
canal is located under the mesiolingual cusp tip. Note the identification of the mesiolingual canal (arrow). F,
Removal of the dentinal cornice that covers the mesiolingual canal to reveal the canal orifice. (See Appen-
dix, Pulpal Anatomy and Access Preparations, for color illustrations showing the size, shape, and location
of the pulp space within each tooth.)
technique, the film/digital sensor is positioned by using a hemostat

approximately parallel to the long axis of the tooth. The cone is then
positioned so that the central beam strikes the film at a 90-degree angle
(Fig. 13.43). Although this technique is reliable, it is not foolproof.68
Other clinical factors should be considered in establishing the
corrected working length. These include tactile sensation,69 the
patient’s response, and hemorrhage. The use of tactile sensation may
be valuable in large tapering canals; however, in small cylindrical
canals, the rate of taper of the files may exceed the rate of taper of the
canal, and binding occurs coronally, giving the false sense of con-
striction. Preflaring the canal before length determination increases
the tactile sensation significantly compared with unflared canals.70
After the film or sensor exposure, the corrected working length
is calculated. The distance from the file tip to the radiographic
apex is determined. If the distance is greater than 1 mm, a calcula-
tion is made (adding or subtracting length) so that the file tip is
Fig. 13.25 The mesiolingual canal as it leaves the pulp chamber. Canals positioned 1 mm from the radiographic apex. If the correction is
that are not negotiable but detected by an explorer may move laterally greater than 3 mm, a second working length radiograph or digital
before proceeding apically.
image should be made with the file placed at the adjusted length.
A B
C D
Fig. 13.26 A, Maxillary left first molar showing calcification. B and C, Initial access and identification of a
pulp stone. Color and a thin line surrounding the periphery identify the hemorrhage. D, The pulp chamber
with the stone removed. (See Appendix, Pulpal Anatomy and Access Preparations, for color illustrations
showing the size, shape, and location of the pulp space within each tooth.)
B
a
A B C
Fig. 13.27 A, The dashed lines show where dentin must be removed to achieve straight-line access. B,
The access completed. C, The original canal (a) is modified using Gates Glidden burs to remove tooth
structure at (B) and (C).
a gag reflex and cannot tolerate films, and patients with medical
problems that prohibit the holding of a film or sensor.
D M The use of apex locators and electric pulp testers in patients
with cardiac pacemakers has been questioned.76-81 In a recent
study involving 27 patients with either implanted cardiac pace-
makers or cardioverter/defibrillators, two impedance apex locators
Fig. 13.28 Lingual outline form for the mandibular incisor. and one electric pulp tester did not interfere with the functioning
of any of the cardiac devices.82 However, it may be advisable not
to use these devices in these patients; other means of length deter-
mination and pulp testing are available.
With angled radiographs or digital images, the canal determi-
nation is based on the buccal object or SLOB rule (same lingual, Study Questions
opposite buccal; see Chapter 3).71,72 Because maxillary anterior
teeth have only one canal, no angle is necessary. Mesial angles 6. Name the potential issues related to inadequate access preparation.
are recommended for premolars and maxillary molars (Fig. a. Less visibility
13.44). Distal angulation is recommended for the mandibular b. Inability to locate canals
incisors and molars (Fig. 13.45). For maxillary posterior teeth, c. Inability to completely remove pulp tissues from the pulp chamber
d. Instrumentation errors caused by lack of straight-line access
the film should be placed on the opposite side of the midline to
e. All of the above
facilitate capture of the palatal roots on the film (see Fig. 13.43).␣ 7. The ridges should be preserved during access preparation whenever
possible.
Electronic Apex Locators a. True
b. False
Apex locators are also used in determining length.73,74 Contem- 8. Which of the following is correct regarding working length
porary apex locators are based on the principle that the flow of determination?
higher frequencies of alternating current is facilitated in a biologic a. Placement of the smallest file to the apex
environment compared with lower frequencies. Passing two differ- b. Placement of the largest file that binds at the apex
ing frequencies through the canal results in the higher frequency c. Removal of the file stopper before placement of the file in the canal
d. Use of files no larger than #
impeding the lower frequency (Fig. 13.46). The impedance values
9. The rubber dam may be removed during radiographic working length
that change relative to each other are measured and converted to determination.
length information. At the apex, the impedance values are at their a. True
maximum differences. Unlike previous models, the impedance b. False
apex locator operates accurately in the presence of electrolytes.75 10. During radiographic working length determination, a new radiograph is
Apex locators are helpful in length determination but must be required if:
confirmed with radiographs. Films or digital images help confirm a. The file is within 1 mm of the apex.
the appropriate length and can identify missed canals. If the file b. The file is at the apex.
is not centered in the root, a second canal is likely to be present. c. The file is more than 2 mm from the apex.
An apex locator is very helpful in patients with structures or d. The file is at the apex.
objects that obstruct visualization of the apex, patients who have
ANSWERS
Answer Box 13 6 e. All of the above
1 a. True 7 a. Truex
2 e. All of the above. 8 b. Placement of the largest file that binds at the apex
3 a. Rubber dam placement may be avoided. 9 b. False
4 a. Before initiation of treatment 10 c. The file is more than 2 mm from the apex.
5 e. All of the above
A B
C D
Fig. 13.29 A, Mandibular lateral incisor. B, Calculation of the estimated depth of access from the middle
of the lingual surface to the coronal extent of the pulp. C, The initial outline form is more oval due to the
receded chamber. D, Completed access.
D M
Fig. 13.30 Lingual ovoid outline form for the mandibular canine.
A B
C D
Fig. 13.31 A, Mandibular canine. B, The initial outline form is established into dentin. C, Exposure of the
coronal pulp. D, The completed access opening.
M D
L
Fig. 13.32 Ovoid outline form for the mandibular first premolar. Note that the access is buccal to the
central groove.
A B
C D
Fig. 13.33 A, Mandibular right first premolar. Note the receded pulp space. B, Calculation of the esti-
mated depth of access. C, The estimated depth of access is reached, and the canal is not located. The
rubber dam is removed and a straight-on parallel radiograph exposed. The film/digital image indicates that
the canal is located mesial to the opening. D, The completed access.
D M
L
Fig. 13.34 Ovoid outline form for the mandibular second premolar.
Fig. 13.35 Rectangular outline form for the mandibular first molar. Note that the mesiobuccal canal is
located under the mesiobuccal cusp, and the mesiolingual canal lies centrally in relation to the crown and
slightly to the distal of the mesiobuccal canal. The distolingual canal is located centrally, and the distobuc-
cal canal lies more buccal and mesial to the main canal.
Lingual
Inclination
Lingual
Constriction
Fig. 13.36 Proximal view of a mandibular molar demonstrating the lingual inclination in the dental arch
and a lingual constriction of the crown at the cementoenamel junction. Note that the mesiobuccal and
mesiolingual canals are uniformly spaced within the root. However, with coronal access, the external refer-
ence points for the canal’s location are the mesiobuccal cusp tip and the central groove as it crosses the
mesial marginal ridge.
B
A
E
Fig. 13.37 A, The preoperative radiograph of a mandibular first molar. B, The completed access cavity
demonstrating the two mesial canals and the single distal canal. C, Cone fit. D, Cone fit radiograph. E,
postoperative radiograph. (See Appendix, Pulpal Anatomy and Access Preparations, for color illustrations
showing the size, shape, and location of the pulp space within each tooth.)
A B
C D
E F
Fig. 13.38 A, Preoperative radiograph of a mandibular first molar with a middle mesial canal. B, Original
working length radiographic image. C, Middle mesial canal located. D, Prepared canal. E, Master cone
radiographic image. F, Postoperative radiographic image of tooth #30.
A B C D
Fig. 13.39 Basic steps in access preparation. A, The access cavity is outlined deep into dentin and
close to the estimated depth of access with the high-speed handpiece. B, Penetration and unroofing are
achieved by fissure high-speed bur or slow-speed latch-type burs. Other bur configurations are accept-
able. C and D, Canal orifices are located and identified with an endodontic explorer. Small files are used
to negotiate to the estimated working length. The dentin shelf that overlies and obscures the orifices is
removed.
A B
C D
E F
Fig. 13.40 A, Access made through gross mesial caries. B, Caries at the level of the crestal bone. C,
Caries removal provides an aseptic operating field and allows assessment of restorability. Note that the
previous access failed to deroof the chamber. D, Appropriate access reveals a ribbon-shaped pulp cham-
ber. E, An orthodontic band placed to provide isolation. F, Post obturation.
A B
Fig. 13.41 A, Parallel preoperative radiograph. B, The mesial working length film is made correctly. The
apices and file tips are clearly visible. Note the mesiolingual canal (arrow).
B
Fig. 13.42 A, Positioning device for holding working films. The ring assists in cone alignment. B, Close-up
view of the device in position.
X-ra
y be
am
Median
Raphe
Fig. 13.43 Proper positioning of the radiograph when making a working length radiograph. To capture the
palatal root, the film should be placed on the opposite side of the midline.
Mesial
Fig. 13.44 Separation of the mesiobuccal and mesiolingual canals achieved by varying the horizontal
angle. With maxillary molars, maximum separation occurs with a mesial cone angulation because of the
mesial location of the mesiolingual canal in relation to the mesiobuccal canal.
Mesial
Fig. 13.45 Separation of the mesiobuccal and mesiolingual canals achieved by varying the horizontal
angle. With mandibular molars, maximum separation occurs with a distal orientation because of the mesial
location of the mesiobuccal canal in relation to the mesiolingual canal.
8. Miller RL, Micik RE: Air pollution and its control in the dental
office, Dent Clin North Am 22:453–476, 1978.
9. Wong RC: The rubber dam as a means of infection control in an era
of AIDS and hepatitis, J Indiana Dent Assoc 67:41–43, 1988.
10. de Andrade ED, Ranali J, Volpato MC, et al.: Allergic reaction after
rubber dam placement, J Endod 26:182–183, 2000.
11. Madison S, Jordan RD, Krell KV: The effects of rubber dam retain-
ers on porcelain fused-to-metal restorations, J Endod 12:183–186,
1986.
12. Zerr M, Johnson WT, Walton RE: Effect of rubber-dam retainers on
porcelain fused to metal, Gen Dent 44:132–134, 1996; quiz, 41–42.
13. Schwartz SF, Foster Jr JK: Roentgenographic interpretation of
experimentally produced bony lesions. I, Oral Surg Oral Med Oral
Pathol 32:606–612, 1971.
14. Jeffrey IW, Woolford MJ: An investigation of possible iatrogenic
damage caused by metal rubber dam clamps, Int Endod J 22:85–91,
1989.
15. Weisman MI: A modification of the No. 3 rubber dam clamp, J
Endod 9:30–31, 1983.
16. Liebenberg WH: Access and isolation problem solving in endodon-
tics: anterior teeth, J Can Dent Assoc 59:663–667, 1993. 70–71.
17. Liebenberg WH: Access and isolation problem solving in endodon-
tics: posterior teeth, J Can Dent Assoc 59:817–822, 1993.
18. Wakabayashi H, Ochi K, Tachibana H, et al.: A clinical technique
A for the retention of a rubber dam clamp, J Endod 12:422–424, 1986.
19. Hermsen KP, Ludlow MO: Disinfection of rubber dam and tooth
surfaces before endodontic therapy, Gen Dent 35:355–356, 1987.
20. Tidmarsh BG: Micromorphology of pulp chambers in human molar
teeth, Int Endod J 13:69–75, 1980.
21. Shaw L, Jones AD: Morphological considerations of the dental pulp
chamber from radiographs of molar and premolar teeth, J Dent
12:139–145, 1984.
22. Patel S, Rhodes J: A practical guide to endodontic access cavity prep-
aration in molar teeth, Br Dent J 203:133–140, 2007.
23. Deutsch AS, Musikant BL: Morphological measurements of ana-
tomic landmarks in human maxillary and mandibular molar pulp
chambers, J Endod 30:388–390, 2004.
24. Abbott PV: Assessing restored teeth with pulp and periapical diseases
for the presence of cracks, caries and marginal breakdown, Aust Dent
J 49(1):33–39, 2004.
25. Patel S, Dawood A, Ford TP, et al.: The potential applications of
cone beam computed tomography in the management of endodon-
tic problems, Int Endod J 40:818–830, 2007.
B 26. Scarfe WC, Levin MD, Gane D, et al.: Use of cone beam computed
tomography in endodontics, Int J Dent 10:20–25, 2009.
Fig. 13.46 A and B, Two impedance apex locators. 27. Clark D, Khademi J: Modern molar endodontic access and directed
dentin conservation, Dent Clin North Am 54:249–273, 2010.
28. Krasner P, Rankow HJ: Anatomy of the pulp-chamber floor, J Endod
References 30:5–16, 2004.
29. Weine FS: Endodontic therapy, ed 6, St. Louis, 2004, Mosby.
1. Cohen S, Schwartz S: Endodontic complications and the law, J 30. Moore B, Verdelis K, Kishen A, et al.: Impacts of contracted end-
Endod 13:191–197, 1987. odontic cavities on instrumentation efficacy and biomechanical
2. Anabtawi MF, Gilbert GH, Bauer MR, et al.: Rubber dam use dur- responses in maxillary molars, J Endod 42(2):1779–1783, 2016.
ing root canal treatment: findings from the dental practice-based 31. Rover G, Belladonna FG, Bortoluzzi EA, et al.: Influence of
research network, J Am Dent Assoc 144:179–186, 2013. access cavity design on root canal detection, instrumentation effi-
3. Lin P, Huang S, Chang H, et al.: The effect of rubber dam usage on cacy, and fracture resistance assessed in maxillary molars, J Endod
the survival rate of teeth receiving root canal treatment: A nation- 43(10):11657–11662, 2017.
wide population-based study, J Endod 40:1733–1737, 2014. 32. Sabeti M, Kazem M, Dianat, et al.: Impact of access cavity design
4. Taintor JF, Biesterfeld RC: A swallowed endodontic file: case report, and root canal taper on fracture resistance of endodontically treated
J Endod 4:254–255, 1978. teeth: an ex vivo investigation, J Endod 44(9):1402–1406, 2018.
5. Forrest WR, Perez RS: AIDS and hepatitis prevention: the role of the 33. Silva EJNL, Rover G, Belladonna FG, et al.: Impact of contracted
rubber dam, Oper Dent 11:159, 1986. endodontic cavities on fracture resistance of endodontically treated
6. Cochran MA, Miller CH, Sheldrake MA: The efficacy of the rubber teeth: a systematic review of in vitro studies, Clin Oral Investig
dam as a barrier to the spread of microorganisms during dental treat- 22(1):109–118, 2018.
ment, J Am Dent Assoc 119:141–144, 1989. 34. Lee MM, Rasimick BJ, Turner AM, et al.: Morphological measure-
7. Samaranayake LP, Reid J, Evans D: The efficacy of rubber dam isola- ments of anatomic landmarks in pulp chambers of human anterior
tion in reducing atmospheric bacterial contamination, ASDC J Dent teeth, J Endod 33:129–131, 2007.
Child 56:442–444, 1989.
35. Deutsch AS, Musikant BL, Gu S, et al.: Morphological measure- 59. Chapman CE: A microscopic study of the apical region of human
ments of anatomic landmarks in pulp chambers of human maxillary anterior teeth, J Br Endod Soc 3:52–58, 1969.
furcated bicuspids, J Endod 31:570–573, 2005. 60. Dummer PM, McGinn JH, Rees DG: The position and topogra-
36. Baldassari-Cruz LA, Lilly JP, Rivera EM: The influence of dental phy of the apical canal constriction and apical foramen, Int Endod J
operating microscope in locating the mesiolingual canal orifice, Oral 17:192–198, 1984.
Surg Oral Med Oral Pathol Oral Radiol Endod 93:190–194, 2002. 61. Ricucci D, Pascon EA, Ford TR, et al.: Epithelium and bacteria in
37. Haselton DR, Lloyd PM, Johnson WT: A comparison of the effects of periapical lesions, Oral Surg Oral Med Oral Pathol Oral Radiol Endod
two burs on endodontic access in all-ceramic high lucite crowns, Oral 101:239–249, 2006.
Surg Oral Med Oral Pathol Oral Radiol Endod 89:486–492, 2000. 62. Ricucci D, Langeland K: Apical limit of root canal instrumentation
38. de Carvalho MC, Zuolo ML: Orifice locating with a microscope, J and obturation. Part 2. A histological study, Int Endod J 31:394–
Endod 26:532–534, 2000. 409, 1998.
39. Kasahara E, Yasuda E, Yamamoto A, et al.: Root canal system of the 63. Ricucci D: Apical limit of root canal instrumentation and obtura-
maxillary central incisor, J Endod 16:158–161, 1990. tion. Part 1. Literature review, Int Endod J 31:384–393, 1998.
40. Dankner E, Harari D, Rotstein I: Dens evaginatus of anterior teeth: 64. Schaeffer MA, White RR, Walton RE: Determining the optimal
literature review and radiographic survey of 15,000 teeth, Oral Surg obturation length: a meta-analysis of literature, J Endod 31:271–
Oral Med Oral Pathol Oral Radiol Endod 81:472–475, 1996. 274, 2005.
41. Gound TG: Dens invaginatus: a pathway to pulpal pathology—a litera- 65. Dummer PM, Lewis JM: An evaluation of the endometric probe in
ture review, Pract Periodontics Aesthet Dent 9:585–594, 1997; quiz, 96. root canal length estimation, Int Endod J 20:25–29, 1987.
42. Green D: Double canals in single roots, Oral Surg Oral Med Oral 66. Forsberg J: A comparison of the paralleling and bisecting-angle radio-
Pathol 35:689–696, 1973. graphic techniques in endodontics, Int Endod J 20:177–182, 1987.
43. Kulild JC, Peters DD: Incidence and configuration of canal systems 67. Forsberg J: Radiographic reproduction of endodontic “working
in the mesiobuccal root of maxillary first and second molars, J Endod length” comparing the paralleling and the bisecting-angle tech-
16:311–317, 1990. niques, Oral Surg Oral Med Oral Pathol 64:353–360, 1987.
44. Pineda F: Roentgenographic investigation of the mesiobuccal root 68. Olson AK, Goerig AC, Cavataio RE, et al.: The ability of the radio-
of the maxillary first molar, Oral Surg Oral Med Oral Pathol 36:253– graph to determine the location of the apical foramen, Int Endod J
260, 1973. 24:28–35, 1991.
45. Stropko JJ: Canal morphology of maxillary molars: clinical observa- 69. Seidberg BH, Alibrandi BV, Fine H, et al.: Clinical investigation of
tions of canal configurations, J Endod 25:446–450, 1999. measuring working lengths of root canals with an electronic device
46. Weine FS, Healey HJ, Gerstein H, et al.: Canal configuration in and with digital-tactile sense, J Am Dent Assoc 90:379–387, 1975.
the mesiobuccal root of the maxillary first molar and its endodontic 70. Stabholz A, Rotstein I, Torabinejad M: Effect of preflaring on tactile
significance, Oral Surg Oral Med Oral Pathol 28:419–425, 1969. detection of the apical constriction, J Endod 21:92–94, 1995.
47. Acosta Vigouroux SA, Trugeda Bosaans SA: Anatomy of the pulp 71. Goerig AC, Neaverth EJ: A simplified look at the buccal object rule
chamber floor of the permanent maxillary first molar, J Endod in endodontics, J Endod 13:570–572, 1987.
4:214–219, 1978. 72. Richards AG: The buccal object rule, Dent Radiogr Photogr 53:37,
48. Benjamin KA, Dowson J: Incidence of two root canals in human man- 1980.
dibular incisor teeth, Oral Surg Oral Med Oral Pathol 38:122–126, 1974. 73. McDonald NJ: The electronic determination of working length,
49. Rankine-Wilson RW, Henry P: The bifurcated root canal in lower Dent Clin North Am 36:293–307, 1992.
anterior teeth, J Am Dent Assoc 70:1162–1165, 1965. 74. Pratten DH, McDonald NJ: Comparison of radiographic and elec-
50. Mauger MJ, Waite RM, Alexander JB, et al.: Ideal endodontic access tronic working lengths, J Endod 22:173–176, 1996.
in mandibular incisors, J Endod 25:206–207, 1999. 75. Fouad AF, Rivera EM, Krell KV: Accuracy of the Endex with varia-
51. Clements RE, Gilboe DB: Labial endodontic access opening for tions in canal irrigants and foramen size, J Endod 19:63–67, 1993.
mandibular incisors: endodontic and restorative considerations, J 76. Beach CW, Bramwell JD, Hutter JW: Use of an electronic apex loca-
Can Dent Assoc 57:587–589, 1991. tor on a cardiac pacemaker patient, J Endod 22:182–184, 1996.
52. Vertucci FJ: Root canal morphology of mandibular premolars, J Am 77. Garofalo RR, Ede EN, Dorn SO, et al.: Effect of electronic apex
Dent Assoc 97:47–50, 1978. locators on cardiac pacemaker function, J Endod 28:831–833, 2002.
53. Vertucci FJ: Root canal anatomy of the human permanent teeth, 78. Moshonov J, Slutzky-Goldberg I: Apex locators: update and pros-
Oral Surg Oral Med Oral Pathol 58:589–599, 1984. pects for the future, Int J Comput Dent 7:359–370, 2004.
54. Hartwell G, Bellizzi R: Clinical investigation of in vivo endodontically 79. Simon AB, Linde B, Bonnette GH, et al.: The individual with a
treated mandibular and maxillary molars, J Endod 8:555–557, 1982. pacemaker in the dental environment, J Am Dent Assoc 91:1224–
55. Skidmore AE, Bjorndal AM: Root canal morphology of the human 1229, 1975.
mandibular first molar, Oral Surg Oral Med Oral Pathol 32:778–784, 80. Woolley LH, Woodworth J, Dobbs JL: A preliminary evaluation of
1971. the effects of electrical pulp testers on dogs with artificial pacemak-
56. Reeh ES, Messer HH, Douglas WH: Reduction in tooth stiffness as ers, J Am Dent Assoc 89:1099–1101, 1974.
a result of endodontic and restorative procedures, J Endod 15:512– 81. Gomez G, Duran-Sindreu F, Jara Clemente F, et al.: The effects of
516, 1989. six electronic apex locators on pacemaker function: an in vitro study,
57. Sedgley CM, Messer HH: Are endodontically treated teeth more Int Endod J 46:399–405, 2013.
brittle? J Endod 18:332–335, 1992. 82. Wilson BL, Broberg C, Baumgartner JC, et al.: Safety of electronic
58. Wilcox LR, Walton RE: The shape and location of mandibular pre- apex locators and pulp testers in patients with implanted cardiac pace-
molar access openings, Int Endod J 20:223–227, 1987. makers or cardioverter/defibrillators, J Endod 32:847–852, 2006.
Video 13.1: Rubber Dam Placement Introduction
Video 13.1A: Placement of Rubber Dam, Clamp, and Frame as a Unit
Video 13.1B: Placement of Clamp, Followed by the Dam and Then the Frame
Video 13.1C: Placement of Rubber Dam and Frame and Then the Clamp
Video 13.2: Access Preparations Introduction
Video 13.2A: Maxillary Incisors
Video 13.2B: Maxillary Canines
Video 13.2C: Maxillary Premolars
Video 13.2D: Finding Additional Canals
Video 13.2E: Maxillary Molars
Video 13.2F: Mandibular Incisors
Video 13.2G: Mandibular Canines
Video 13.2H: Mandibular Premolars
Video 13.2I: Mandibular Molars
Video 13.3: Working Length Determination
296.e1
14
Cleaning and Shaping ↑
OVE A. PETERS, ANA ARIAS, AND SHAHROKH SHABAHANG
CHAPTER OUTLINE
Principles of Cleaning and Shaping, 297 Lubricants, 307
Apical Canal Preparation, 298 Preparation Errors, 307
Pretreatment Evaluation, 302 Preparation Techniques, 309
Principles of Cleaning and Shaping Techniques, 303 Criteria for Evaluating Cleaning and Shaping, 317
Smear Layer Management, 304 Intracanal Medicaments, 320
Irrigants, 305
LEARNING OBJECTIVES
After reading this chapter, the student will be able to: 6. Distinguish between apical stop, apical seat, and open apex,
1. State reasons and describe strategies for enlarging the cervical and discuss how to manage obturation in each.
portion of the canal to promote straight-line access. 7. Describe appropriate techniques for removing the pulp.
2. Define how to determine the appropriate size of the master 8. Characterize the difficulties of preparation in the presence
apical file. of anatomic aberrations that make complete débridement
3. Describe objectives for biomechanical cleaning and shaping difficult.
and explain how to determine when these have been achieved. 9. Describe techniques for negotiating severely curved, “blocked,”
4. Illustrate shapes of differently created preparations and draw “ledged,” or constricted canals.
these both in longitudinal and cross-sectional diagrams. 10. Discuss the properties and role of intracanal, interappointment
5. Describe techniques for shaping canals that have irregular medicaments.
shapes, such as round, oval, hourglass, bowling pin, kidney
bean, or ribbon.
Successful long-term outcomes of root canal treatment are based after cleaning and shaping will help to entomb any remaining
on establishing an accurate diagnosis and developing an appro- organisms3 and, with the coronal seal, prevent or at least delay
priate treatment plan; applying knowledge of tooth anatomy and recontamination of the canal and periradicular tissues. However,
morphology (shape); and performing débridement, disinfection, some bacterial species have been shown to survive entombment.4
and obturation of the entire root canal system while maintaining These classic concepts define success in endodontics by healing
the strength of the tooth. Historically, emphasis was on obtura- of apical periodontitis if present preoperatively or the prevention
tion and sealing the radicular space. However, no technique or of its occurrence in case that began with normal periapical tissues.
material provides a seal that is completely impervious to moisture However, in recent years, it has been demonstrated that vertical
from either the apical or coronal aspects. Early studies on progno- fracture or other nonendodontic causes are the major reasons for
sis indicated failures were attributable to incomplete obturation.1 the eventual loss of root canal–treated teeth.5 As a result, a more
This proved fallacious as obturation merely reflects the adequacy of patient-centered outcome as increased susceptibility to fracture
the cleaning and shaping. Canals that are poorly obturated may be should be considered. Functional retention of the endodontically
incompletely cleaned and shaped. Adequate cleaning and shaping treated tooth may serve as a relevant endpoint in endodontic treat-
and establishing a coronal seal are essential elements for success- ment,6 which may compliment but should not replace the tradi-
ful treatment, with obturation being less important for short- tional focus on healing or prevention of apical periodontitis.
term success.2 Elimination (or significant reduction) of inflamed
or necrotic pulp tissue and microorganisms are the most critical Principles of Cleaning and Shaping
factors. The role of obturation in long-term success has not been
established but may be significant in preventing recontamination Nonsurgical root canal treatment is a predictable method of
either from the coronal or apical direction. Sealing the canal space retaining a tooth that otherwise would require extraction. Success
297
298 C HA P T E R 1 4 Cleaning and Shaping
Frequent and effective irrigation is necessary to achieve this goal.

At the same time, root canals need to be enlarged to allow irrigants
to properly clean the canal and to remove contaminated dentin.
Irrigants readily remove microorganisms from the coronal third of
a root canal, but further shaping is necessary to eliminate bacteria
in less accessible canal areas. Meanwhile, the mechanical action of
instruments generates debris that is typically pushed into acces-
sory anatomy and may block the access to subsequent irrigation.
This debris also needs to be flushed and removed. Therefore it is
imperative to use mechanical shaping and irrigation in synergy to
maximize antibacterial efficacy of endodontic procedures.
Apart from enhancing cleaning procedures, another purpose of
shaping is to provide space for an effective filling of the root canal
space. The main mechanistic objective of shaping is to maintain
or develop a continuously tapering funnel from the canal orifice
Cross-section through a root showing the main canal (C) and a
to the apex. Conceptually, the degree of enlargement is partly
fin (arrow) and associated cul-de-sac after cleaning and shaping using files dictated by the method of obturation. For lateral compaction of
and sodium hypochlorite. Note the tissue remnants in the fin. gutta-percha, the canal should be enlarged sufficiently to permit
placement of the spreader to within 1 to 2 mm of the working
length (WL).8 For warm vertical compaction techniques, the
coronal enlargement must permit the placement of pluggers to
within 3 to 5 mm of the WL.9
However, the more dentin is removed from the canal walls,
the less resistant to fracture the root becomes.10 Micronized gutta-
percha points for vertical compaction that allows melting at larger
distances from the heat source are now available in order to allow
proper obturation of more conservative preparations. New mate-
rials based on the concept of so-called hydraulic obturation tech-
niques are also marketed for the same purpose. However, as always,
clinicians should select an obturation technique judiciously, based
on available evidence.
Ideally, the degree of shaping should be tooth dependent and
not depend on the obturation technique. As an example, narrow
thin roots, such as mandibular incisors, may not permit the same
degree of enlargement as more bulky roots, such as the maxillary
central incisors.␣
Apical Canal Preparation

Termination of Cleaning and Shaping
Although the concept of cleaning and shaping the root canal space
The main canal (C) has a lateral canal (arrow) extending to the appears to be straightforward, there are areas where consensus does
root surface. After cleaning and shaping with sodium hypochlorite irriga- not exist. The first is the extent of the apical preparation. Early
tion, tissue remains in the lateral canal. studies identified the dentinocemental junction as the area where
the pulp ends and the periodontal ligament begins. Unfortunately,
this is a histologic landmark and the position (which is irregular
of root canal treatment in a tooth with a vital pulp is higher than within the canal) cannot be determined clinically.
that of a tooth diagnosed with necrotic pulp and periradicular Traditionally, the apical point of termination, also known as WL,
pathosis.7 has been 1 mm from the radiographic apex. A classic study described
The reason for this difference in outcome is the persistent pres- the apical portion of the canal with the major diameter of the fora-
ence of microorganisms and their metabolic byproducts. The most men and the minor diameter of the constriction (Fig. 14.4).11 The
significant factors affecting the clinician’s inability to completely apical constriction is defined as the narrowest portion of the canal,
remove intracanal microorganisms are tooth anatomy and mor- and the average distance from the foramen to the constriction was
phology. Instruments are believed to contact and plane the canal found to be 0.5 mm. Another study found the classic apical con-
walls to débride the canal (Figs. 14.1 to 14.4), aided by irrigating striction to be present in only 46% of the teeth and, when present,
solutions. Morphologic factors include lateral (see Fig. 14.2) and varied in shape and in relation to the apical foramen.12 Variations
accessory canals, canal curvatures, canal wall irregularities, fins, from the classic appearance consist of the tapering constriction,
cul-de-sacs (see Fig. 14.1), and isthmuses. These aberrations ren- multiple constrictions, and a parallel apical canal part.12 To com-
der full wall contact and therefore complete débridement virtu- plicate the issue, the foramen is rarely located at the anatomic apex.
ally impossible. Consequently, a practical objective of cleaning is Convincing micro–computed tomography data provide a more
to significantly reduce the irritants, not totally eliminate them. realistic portrait of apical canal morphology (Fig. 14.5).
CHAPTER 14 Cleaning and Shaping 299
A B
(A) No. 15 file in the apical canal space. Note the size is inadequate for planing the walls. (B) No.
40 file more closely approximates the canal morphology. (Courtesy Dr. Randy Madsen.)
A B
C D
(A) The classic apical anatomy consisting of the major diameter of the foramen and the minor
diameter of the constriction. (B) An irregular ovoid apical canal shape and external resorption. (C) A bowl-
ing pin apical morphology and an accessory canal. (D) Multiple apical foramina.
A B
C
(A) Micro–computed tomography (micro-CT) reconstruction of an unprepared root canal sys-
tem of a maxillary molar. (B) Prepared canal system, enlarged to an apical size 30 in the palatal and 25
in the mesiobuccal and distobuccal canal. (C) Magnified view of the initial canal configuration for all three
apices.
Apical anatomy has also been shown to be quite variable (see of materials decreases success.7,18,19 In one study examining cases
Figs. 14.4, B, and 14.5). A study found no typical pattern for with pulp necrosis, better success was achieved when the proce-
foraminal openings and that no foramen coincided with the apex dures terminated at or within 2 mm of the radiographic apex.
of the root.13 The same group reported the foramen to apex dis- Obturation shorter than 2 mm from the apex or past the apex
tance to range from 0.20 to 3.8 mm. resulted in a decreased success rate. In teeth with vital inflamed
It has also been noted that the foramen to constriction distance pulp tissue, termination between 1 and 3 mm was acceptable.18
increases with age,11 and root resorption may destroy the classic Two larger studies confirmed that overfill was associated with infe-
anatomic constriction.14 Resorptive processes are common with rior outcomes.7,19
pulp necrosis and apical bone resorption. Therefore root resorp- At the same time, working short presents higher risks of accu-
tion is an additional factor to consider in length determination. mulation and retention of debris, which in turn may result in api-
In a prospective study, significant adverse factors influencing cal blockage and may contribute to procedural errors in the first
success and failure were the presence of a perforation, preopera- place; furthermore, infected debris, bacteria, and their byproducts
tive periradicular disease, and incorrect length of the root canal can remain in the most apical portion of the canal in cases with
filling.15,16 The authors speculated that canals filled more than pulpal necrosis jeopardizing apical healing and contributing to a
2.0 mm short harbored necrotic tissue, bacteria, and irritants that persistent or recurrent apical periodontitis20,21 or posttreatment
when retreated could be cleaned and sealed.15 A meta-analysis disease.22,23
evaluation of success and failure indicated a better success rate Most publications on outcomes that extrapolate the effect of
when the obturation was confined to the canal space.17 A review apical termination are retrospective. On the other hand, a recent
of several studies on endodontic outcomes confirms that extrusion prospective study demonstrated that not only the maintenance
of apical patency, but also the apical extent of canal cleaning, is is discussed in the following section) but may decrease antimi-
a significant prognostic factor for root canal treatment, recom- crobial efficacy of cleaning procedures. It appears that with tra-
mending extending canal cleaning as close as possible to its api- ditional hand instruments, apical transportation occurs in many
cal terminus. In that study, the odds of success were reduced by curved canals enlarged beyond a No. 20 stainless steel file.24
12% for every 1 mm of the canal short of the terminus remaining The criteria for cleaning and shaping should be based on the
“uninstrumented.”7 ability to adequately deliver sufficient amounts of irrigant and not
Therefore the exact clinical point of apical termination of the on a specific obturation technique. The ability of irrigants to reach
preparation and obturation remains a matter of debate. The need the apical portion of the root canal depends on canal’s size, taper,
to compact the gutta-percha and sealer against the apical den- and the irrigation device used.25-27
tin matrix (constriction of the canal) is important in creating a Larger preparation sizes have been shown to provide adequate
seal. The decision of where to terminate the preparation is based irrigation and debris removal and significantly decrease the num-
on knowledge of apical anatomy, tactile sensation, radiographic ber of microorganisms.28-31 However, any removal of dentin has
interpretation, apex locators, apical bleeding, and the patient’s the potential to weaken radicular structure and therefore the use
response. To prevent extrusion, the cleaning and shaping proce- of an irrigation adjunct designed to promote irrigation efficacy in
dures should be confined to the radicular space. Canals filled to smaller canals may be advantageous.32,33
the radiographic apex are actually slightly overextended.13␣ In principle there may to be a relationship between increasing
the size of the apical preparation and canal cleanliness34 and bacte-
rial reduction.35,36 Instrumentation techniques that advocate min-
Degree of Apical Enlargement imal apical preparation may be ineffective at achieving the goal of
Generalizations can be made regarding tooth anatomy and mor- cleaning and disinfecting the root canal space.34,36 However, this
phology, although each tooth is unique. Length of canal prepa- concept reaches its limits when too large a preparation leads to
ration is often emphasized with little consideration given to procedural errors37,38 and when modifications created in the hard
important factors such as canal diameter and shape. Because mor- tissue block the very anatomy that was to be cleaned (Fig. 14.6).39
phology is variable, there is no standardized apical canal size. Tra- A variety of microbial species can penetrate deep into dentinal
ditionally, preparation techniques were determined by the desire tubules.40 These intratubular organisms are sheltered from endodon-
to limit procedural errors and by the method of obturation. Small tic instruments, the action of irrigants, and intracanal medicaments.
apical preparation reduces the incidence of preparation errors (as Dentin removal appears to be the primary method for decreasing
B
(A) Individual micro–computed tomography scans from the apical root third of a typical speci-
men before and after root canal preparation and irrigation with sodium hypochlorite (NaOCl), subsequent
irrigation with ethylenediaminetetraacetic acid and final passive ultrasonic irrigation using again NaOCl
(from left to right). (B) The corresponding three-dimensional reconstructions of the whole canal system
are depicted below. (Reprinted from Paqué F, Boessler C, Zehnder M: Accumulated hard tissue débris
levels in mesial roots of mandibular molars after sequential irrigation steps, Int Endod J 44(2):148, 2011
with permission.39)
their numbers. However, it may not be possible to remove bacteria during cleaning and shaping procedures is to ensure that WL is
that are deep in the tubules, regardless of the technique. There is a not lost and that the apical portion of the root is not packed with
correlation between the number of organisms present and the depth tissue, dentin debris, and bacteria (see Fig. 14.6, A). The patency
of tubular penetration41; in teeth with apical periodontitis, bacteria concept has historically been controversial; indeed, concerns
may penetrate the tubules to the periphery of the root.42,43␣ regarding possible extrusion of dentinal debris, bacteria, and irrig-
ants have been raised,61 a condition often considered to result in
postoperative pain and possibly delayed healing.62
Elimination of Etiology However, a large retrospective study identified the presence of
The development of nickel-titanium (NiTi) instruments has dra- apical patency as a factor possibly associated with higher success
matically changed the techniques of cleaning and shaping; these rates.7 Moreover, at least in vitro, microorganisms do not appear
instruments have been rapidly adopted by clinicians in many to be transported beyond the confines of the canal by patency fil-
countries.44-46 The primary advantage to using these flexible ing.63 Small files are not directly effective in débridement (see Fig.
instruments is related to shaping, specifically a significant reduc- 14.3) but achieving patency may be helpful in enhancing irriga-
tion in the incidence of preparation errors.37 tion efficacy,64 determining electronic WL, minimizing the risk of
Neither hand instruments nor rotary files have been shown to com- loss of length, reducing shaping mishaps such as canal transporta-
pletely débride the canal.29,47,48 Mechanical enlargement of the canal tion and ledges,65 better maintaining the anatomy of the apical
space dramatically decreases the presence of microorganisms present constriction,66 and improving clinicians’ tactile sense during api-
in the canal49 but cannot render the canal sterile.29 Therefore antimi- cal shaping.67
crobial irrigants have been recommended in addition to mechanical Studies evaluating treatment failure have noted, besides
preparation techniques.50 There is currently no consensus on the most several other factors, presence of bacteria outside the radicular
appropriate irrigant or concentration of solution, although sodium space,20 and bacteria have in some cases been shown to exist as
hypochlorite (NaOCl) is the most widely used irrigant.51 plaques or biofilms on the external root structure.68 It has been
Unfortunately, solutions such as NaOCl that are designed to kill shown in vitro that maintaining patency may be connected to
bacteria50,52,53 are often toxic for the host cells,54-57 and therefore small amounts of irrigant to reach the periodontium, but this
extrusion beyond the canal space is to be avoided.58,59 A major fac- did not appear to increase the chance of irrigation accidents in
tor related to effectiveness is the volume of irrigant used during the the clinic.69
procedure. Increasing the volume produces cleaner preparations.60␣ Moreover, a recently published systematic review concluded
that maintaining apical patency was not associated with postop-
erative pain in teeth with either vital or nonvital pulp.70 For all
Apical Patency these reasons the benefits of maintaining apical patency seem to
Apical patency is a technique that advocated the repeated place- outweigh possible risks.␣
ment of small hand files to or slightly beyond the apical foramen
during canal preparation (Fig. 14.7). A benefit of this technique Pretreatment Evaluation
Before treatment, each case should be evaluated for its degree of
difficulty. The American Association of Endodontists has devel-
oped The Endodontic Case Difficulty Assessment Form, a practi-
cal tool that helps practitioners to identify the complexities that
should not be overlooked before starting a root canal treatment.
All three, patient, diagnostic, and treatment aspects, are con-
sidered to identify the level of difficulty of a specific case and
help in 3 minutes to both anticipate problems the clinician may
have during the treatment and determine whether the complex-
ity of the case is suitable for the clinician’s level of expertise and
comfort.
Normal anatomy and anatomic variations are determined,
as well as variations in canal morphology.71 The mishandling
of natural difficulties will lead to procedural mishaps that will
be even more difficult to manage. A root canal that seems to
be straight in a radiograph may have multiple curvatures in
three dimensions that are not captured using a two-dimen-
sional film. Therefore more than one preoperative radiograph
might be needed for a proper assessment; a cone beam scan or
cone beam computed tomography (CBCT) may also help to
determine the best strategy to shape the most difficult canal
anatomies.
Specifically, the longer a root, the more difficult it is to treat;
apically, a narrow, curved root is susceptible to perforation; in
multirooted teeth, a narrow area midroot could result in a strip-
A small file (No. 10 or 15) is placed beyond the radiographic ping perforation toward the root concavity. The degree and loca-
apex to maintain patency of the foramen. Note the tip extends beyond the tion of curvature are determined. Canals are seldom straight,
apical foramen. and curvatures in a buccolingual direction are normally not
visible on the radiograph. Sharp curvatures or dilacerations are may reach WL during Stage 2; for example, if there is only
more difficult to manage than a continuous gentle curve. Roots one curvature. If preoperative assessments have indicated that
with an S-shape or bayonet configuration are very difficult to an S-shape or multiple curvatures are present, it may be useful
treat. Intracanal mineralization will also complicate treatment. to introduce a Stage 3 that finally reaches the estimated WL,
Such mineralization generally occurs in a coronal to apical direc- whereas Stage 2 provides additional enlargement into the sec-
tion, thus a large tapering canal may become more cylindrical ondary curvature.75
with irritation or age. However, the appearance of proprietary thermal treatments
The presence of resorption also will complicate treatment. of NiTi alloys with different series of heating and cooling treat-
With internal resorption, it is difficult to pass instruments ments has led to the enhancement of the mechanical properties
through the coronal portion of the canal and the resorptive of contemporary rotary instruments by optimizing the micro-
defect and into the apical portion. Also, files will not remove tis- structural characteristics of the alloy. The higher flexibility and
sue, necrotic debris, and bacteria from such a resorptive defect. cyclic fatigue resistance of these new instruments provides better
External resorption may perforate the canal space and present clinical behavior and allows dentin preservation in the coronal
problems with hemostasis and isolation. Restorations may third of many cases with a minimal orifice modification in Stage
obstruct access and visibility, as well as change the orientation of 1. Scientific evidence suggests that preserving pericervical den-
the crown in relation to the root.␣ tin (4 mm above and below the crestal bone) is crucial for the
distribution of functional stresses and the maintenance of the
strength of the tooth and long-term survival.76 Computational
Principles of Cleaning and Shaping simulations with finite element analysis showed that masticatory
Techniques stresses are reduced even when small amounts of this pericervical
dentin are preserved.77
Cleaning and shaping are separate and distinct concepts but The authors strongly believe in this minimally invasive compo-
are performed concurrently. The criteria of canal preparation nent of the technique because overflaring is liable to reduce den-
include developing a continuously tapered funnel, maintaining tinal wall thickness and structural strength and perhaps overall
the original shape of the canal, maintaining the apical foramen restorability (see Fig. 14.8). On the other hand, when it is per-
in its original position, keeping the apical opening as small as formed with an instrument that allows a selective removal of den-
possible, and developing glassy smooth walls.9 The cleaning and tin because of a limited maximum fluted diameter (MFD) that
shaping procedures are designed to maintain an apical matrix for provides a conservative coronal preparation, early coronal flar-
compacting the obturating material regardless of the obturation ing is also beneficial for the earlier access of disinfecting irriga-
technique.9 tion solutions, better tactile control of hand instruments during
Knowledge of a variety of techniques and instruments for treat- negotiation, and the easier placement of files in the delicate apical
ment of the myriad variations in canal anatomy is required. There third.78
is no consensus or clinical evidence on which technique or instru- In general, the use of NiTi rotary instruments to WL should
ment design or type is clinically superior (Video 14.3).38,72 be preceded by a manual exploration of the canal to the desired
NiTi files have been incorporated into endodontics because of preparation length, also known as glide path verification. This
their flexibility and resistance to cyclic fatigue.73 The resistance step is performed with one or more small K-files that are not
to cyclic fatigue permits these instruments to be used in a rotary precurved. In recent years, NiTi rotary instruments have been
handpiece, which gives them an advantage over stainless steel files. specifically designed to simplify the process of glide path prepa-
NiTi files are manufactured in both hand and rotary versions and ration after a negotiating file has previously reached WL. If it
have been demonstrated to produce superior shaping compared is possible to predictably reach WL without precurving, rotary
with stainless steel hand instruments (Video 14.1).37,72,74 instruments may be used to the desired length. However, caution
NiTi instruments are available in a variety of designs, many should be exercised in S-shaped canals, canals that join within a
with increased taper compared with .02 mm standardized stainless single root, and canals with severe dilacerations. Canals in which
steel files. The superelasticity of NiTi alloy enabled the manufac- ledge formation is present, and very large canals where instru-
turing of more tapered instruments still flexible enough to prop- ments fail to contact the canal walls, do not lend themselves to
erly shape canals with different angles and radius of curvature. The rotary preparation.
increase in the taper provides better and more continuous shapes Instrument fracture can occur as a result of torsional loading or
with the use of fewer instruments and in a shorter period of time. cyclic fatigue.38 Torsional forces develop because of frictional resis-
Common tapers are .04 and .06, and the tip diameters may or tance; therefore as the surface area increases along the flutes, the
may not conform to the traditional manufacturing specifications. greater the friction and the more potential for fracture. Torsional
The file systems can vary the taper while maintaining the same stress can be reduced by limiting file contact, using a crown-down
tip diameter or they can employ varied tapers with International preparation technique, by verifying a glide path to WL, and with
Organization for Standardization (ISO) standardized tip diam- the presence of liquid irrigants such as NaOCl during shaping
eters; some NiTi instruments have multiple tapers along their procedures.
cutting portions, with more recent instruments featuring smaller Cyclic fatigue occurs as a file rotates in a curved canal.79 At
maximum fluted diameters of less than 1 mm at the end of the the point of curvature the outer surface of the file is under ten-
fluted instrument portion. sion while the inner surface of the instrument is compressed.
A rational concept of root canal preparation using current As the instrument rotates, the areas of tension and compres-
instruments unfolds in stages. Classically, Stage 1 is a defined sion alternate, crack initiation begins, ultimately leading to
preflaring, before bringing any hand file to the apical third of the fracture. There is often no visible evidence that fracture is
canal. Depending on the expected canal difficulty, instruments imminent.
B C D
An endodontically treated mandibular molar through constricted access and limited shaping,
highlighting its guidelines by area: (A) coronal, (B) pericervical, (C) radicular body, and (D) apical. (Reprinted
from Boveda C, Kishen A: Contracted endodontic cavities: the foundation for less invasive alternatives in
the management of apical periodontitis. Endod Topics 33:169, 2015 with permission.)
Smear Layer Management

1. Endodontic treatment failures result from all except which of the During cleaning and shaping, organic components of pulp tis-
following?
sue and inorganic dentinal debris accumulate that are not only
a. Inadequate root canal débridement
b. Use of hand instrumentations
pressed into accessory canals, fins, and isthmuses (Fig. 14.6) but
c. Coronal leakage also deposited on the radicular canal wall, producing an amor-
d. Bacteria that are more resistant to treatment protocols phous, irregular smear layer (Fig. 14.9).81 With pulp necrosis, the
2. Use of antimicrobial irrigants is an optional component of root canal smear layer may be contaminated with bacteria and their meta-
débridement because new technologic advancements in file design bolic byproducts. The smear layer is superficial, with a thickness
allow better adaptation to canal irregularities. of 1 to 5 µm, and debris can be packed into the dentinal tubules
a. True to varying distances.82
b. False There is not a consensus on removing the smear layer before
3. Precise location of the apical constriction may be difficult to identify obturation.81,83,84 The advantages and disadvantages of the smear
because of which of the following?
layer removal remain controversial; however, evidence generally
a. The location of the apical foramen may vary
b. The apical constriction can be altered by inflammatory changes
supports removing the smear layer before obturation.81,85 The
c. The canal terminus is not always located at the root apex organic debris present in the smear layer might constitute substrate
d. All of the above for bacterial growth, and it has been suggested that the smear layer
3. Iatrogenic root perforation can adversely affect endodontic treatment prohibits sealer contact with the canal wall, which permits leak-
outcome. age. In addition, viable microorganisms in the dentinal tubules
a. True may use the smear layer as a substrate for sustained growth. When
b. False the smear layer is not removed, it may slowly disintegrate with
4. Maintenance of pericervical dentin contributes to the resistance to leaking obturation materials, or it may be removed by acids and
fractures that may be caused by masticatory forces. enzymes that are produced by viable bacteria left in the tubules or
a. True
that enter via coronal leakage.3 The presence of a smear layer may
b. False
also interfere with the action and effectiveness of root canal irrig-
ants and interappointment disinfectants.53
With smear layer removal, filling materials adapt better to
Although new thermomechanical processed alloys have the canal wall.86,87 Removal of the smear layer also enhances
improved lifespan of instruments, it is still advised that the use the adhesion of sealers to dentin and tubular penetration83,86-88
of NiTi instruments be monitored80 and limited to a reduced and permits the penetration of all sealers to varying depths.89
number of cases. For difficult or calcified or severely curved Removal of the smear layer reduces both coronal and apical leak-
canals, it is recommended the instruments be used only once.72␣ age (Video 14.2).85,90␣
A B
(A) A canal wall with the smear layer present. (B) The smear layer removed with 17% ethylene-
diaminetetraacetic acid.
BOX 14.1
Organic tissue solvent
Inorganic tissue solvent
Antimicrobial action
Nontoxic
Low surface tension
Lubricant
Irrigants
The ideal properties for an endodontic irrigant are listed in Box
14.1.81 Currently, no solution meets all the requirements out-
lined. In fact, no techniques appear able to completely clean the
root canal space.39,91-93 Frequent irrigation is necessary to flush
and remove the debris generated by the mechanical action of the
instruments. At the same time, preparation of radicular wall cre-
ates hard tissue debris that is typically pushed into accessory anat-
omy, blocking access for subsequent irrigation.39 Therefore it is A B
imperative to use mechanical shaping and irrigation in synergy to (A and B) For effective irrigation the needle must be placed in
maximize antibacterial efficacy of endodontic procedures. the apical one-third of the root and must not bind.
Sodium Hypochlorite effectiveness of the solution.100,101 However, NaOCl has limita-

tions to tissue dissolution in the canal, because of limited contact
The most common irrigant is NaOCl, which is also known as with tissues in all areas of the canal.
household bleach. Advantages to NaOCl include the mechani- Because of toxicity, extrusion is to be avoided.55,59,102 The irri-
cal flushing of debris from the canal, the ability of the solution gating needle must be placed loosely in the canal (Fig. 14.10), and
to dissolve vital94 and necrotic tissue,95 the antimicrobial action the use of side-vented needles specifically designed for endodontic
of the solution,47 and the lubricating action.96 In addition, it is irrigation is recommended in order to avoid accidents. Insertion
inexpensive and readily available.97 to binding and slight withdrawal minimizes the potential for pos-
Free chlorine in NaOCl dissolves necrotic tissue by breaking sible extrusion and an NaOCl accident (Fig. 14.11). Special care
down proteins into amino acids. There is no proven appropri- should be exercised when irrigating a canal with an open apex.
ate concentration of NaOCl, but concentrations ranging from To control the depth of insertion the needle is bent slightly at the
0.5% to 5.25% have been recommended. A common concentra- appropriate length or a rubber stopper is placed on the needle.
tion is 2.5%, which decreases the potential for toxicity yet still Most likely, any irrigant does not travel apically more than
maintains some tissue dissolving and antimicrobial activity.98,99 1 mm beyond the irrigation tip, so deep placement with small-
Because the action of the irrigant is related to the amount of free gauge needles enhances irrigation (see Fig. 14.10).103 During
chlorine, decreasing the concentration can be compensated by rinsing, the needle is moved up and down constantly to produce
increasing the volume. Warming the solution can also increase the agitation and prevent binding or wedging of the needle.␣
A possible alternative to citric acid or EDTA recently suggested

is HEBP. HEBP is a weak and biocompatible chelator that pre-
vents bone resorption and is used systemically in patients suffer-
ing from osteoporosis or Paget’s disease.98 In contrast with EDTA
or citric acid, HEBP appeared to reduce NaOCl active chlorine
content after 1 hour and reduction continued over time, but the
mixture seemed not to interfere with the dissolving properties
of NaOCl. Therefore it may be mixed and used in combination
with NaOCl, reducing the formation of smear layer during the
mechanical preparation of the root canal. It seems that 7% to 10%
HEBP could be mixed chair-side with NaOCl, without fearing
any loss of NaOCl activity and administered during the whole
course of root canal preparation.107␣
A B Chlorhexidine
(A and B) A sodium hypochlorite accident during treatment of Chlorhexidine possesses a broad spectrum of antimicrobial
the maxillary left central incisor. Extensive edema occurred in the upper lip
activity, provides a sustained action,102,120 and has little tox-
and was accompanied by severe pain.
icity.121-124 Two percent chlorhexidine has similar antimicro-
bial action as 5.25% NaOCl121 and is more effective against
Enterococcus faecalis.102 NaOCl and chlorhexidine are synergis-
Chelating Irrigants: Ethylenediaminetetraacetic tic in their ability to eliminate microorganisms.122 A disadvan-
Acid, Citric Acid, Hydroxyethylidene tage of chlorhexidine is its inability to dissolve necrotic tissue
and remove the smear layer. Moreover, clinical studies do not
Bisphosphonate confirm that the use of chlorhexidine is associated with better
As described previously, NaOCl is the most effective irrigant for outcomes.7
organic tissue dissolution and elimination of bacteria biofilm; Moreover, the interaction between chlorhexidine and NaOCl
however, it does not remove inorganic tissue. For this reason, it produced a precipitate that may have detrimental consequences
needs to be combined with a chelating agent, such as ethylene- for endodontic therapy; among them it may produce discolor-
diaminetetraacetic acid (EDTA), citric acid, or the more recently ation and potential toxic substances for periradicular tissues. At
suggested hydroxyethylidene bisphosphonate (HEPB), also called the same time, when chlorhexidine interacted with EDTA a pre-
etidronate. The chelating activity is directed toward removal of the cipitate was also produced.106,125␣
smear layer because, in fact, these chelators have minimal tissue
dissolution capacity.104
EDTA 105 is the most frequently used irrigant for this purpose.
MTAD
However, chemical interactions between EDTA and NaOCl have An alternative method for disinfecting while at the same time
been described, and when combined, tissue dissolution ability of removing the smear layer employs a mixture of a tetracycline iso-
NaOCl may be affected as a result of a reduction in the active chlo- mer, an acid, and a detergent (MTAD) as a final rinse to remove
rine content.106,107 For this reason, when using EDTA, the irrigation the smear layer.126 The effectiveness of MTAD to completely
protocol recommended includes an irrigation with 17% EDTA for 1 remove the smear layer is enhanced when low concentrations
minute at the end of the shaping procedure followed by a final rinse of NaOCl are used as an intracanal irrigant before the use of
with NaOCl.108 Chelators such as EDTA remove the inorganic com- MTAD.127 A 1.3% concentration is recommended. MTAD may
ponents and leave the organic tissue elements intact. NaOCl is then be superior to NaOCl in antimicrobial action.128,129 MTAD
necessary for removal of the remaining organic components; however, has been shown to be effective in killing E. faecalis, an organ-
the additional use of NaOCl after chelating agents may lead to exces- ism commonly found in failing treatments, and may prove
sive demineralization of radicular wall dentin.109 beneficial during retreatment. It is biocompatible,130 does not
Demineralization results in removal of the smear layer and alter the physical properties of the dentin,130 and enhances
plugs and enlargement of the tubules.110,111 The action is most bond strength.131 Although there are encouraging in vitro data,
effective in the coronal and middle thirds of the canal whereas the MTAD has not been shown to be clinically beneficial at this
effect is diminished in the apical third.105,112 point.132␣
Reduced efficacy may be a reflection of canal size113 or ana-
tomic variations such as irregular or sclerotic tubules.114,115 The
variable structure of the apical dentin presents a challenge during
QMix
endodontic obturation with adhesive materials. A chlorhexidine-based mixture, marketed as QMix,133 employs a
The recommended time for removal of the smear layer with similar underlying strategy with the potential to not only remove
EDTA is 1 minute.105,116,117 The small particles of the smear layer smear layer but also to provide antibiofilm activity. QMix consists
are primarily inorganic with a high surface to mass ratio, which of a proprietary mix of chlorhexidine, EDTA, and a surface-active
facilitates removal by acids and chelators. EDTA exposure over 10 agent. Nothing is known about its contribution to clinical out-
minutes causes excessive removal of both peritubular and intratu- comes, but it appears that smear layer removal is similar to 17%
bular dentin.117 A 10% solution of citric acid has also been shown EDTA,134 and antimicrobial effects are adequate.135,136 However,
to be an effective method for removing the smear layer, although it tissue dissolution with prior canal shaping and use of NaOCl are
also reduces available chlorine in NaOCl solutions.118,119 still required.137␣
Irrigants for Cryotherapy rotation of the file carries the material apically. The file can then be
worked to length using a watch winding motion.
A new use of irrigant solution has been recently described in root Paste lubricants can incorporate chelators. One advantage
canal treatment. Posttreatment pain is a very common situation, to paste lubricants is that they can suspend dentinal debris and
especially in teeth presenting with preoperative pain, pulp necro- prevent apical compaction. One proprietary product consists of
sis, and symptomatic apical periodontitis. Postoperative pain glycol, urea peroxide, and EDTA in a special water-soluble base.
has traditionally been controlled with paracetamol, nonsteroidal It has been demonstrated to exhibit an antimicrobial action.152
antiinflammatory medication, opioids, and/or corticosteroids. In Another type is composed of 19% EDTA in a water-soluble vis-
other fields of medicine, other alternatives have been suggested cous solution.
in search of a greater efficacy for pain control while avoiding sec- A disadvantage to these EDTA compounds appears to be the
ondary effects, cryotherapy among them. A controlled irrigation deactivation of NaOCl by reducing the available chlorine153 and
with cold saline after cleaning and shaping procedures has been potential toxicity.154 The addition of EDTA to the lubricants has
recently suggested to reduce incidence and intensity of postop- not proved to be effective.155 In general, files remove dentin faster
erative pain in those patients presenting symptomatic apical peri- than the chelators can soften the canal walls. Aqueous solutions,
odontitis.138 The authors suggested a final irrigation after cleaning such as NaOCl, should always be used instead of paste lubricants
and shaping with cold (2.5°C) sterile saline solution, also using a when using NiTi rotary techniques to reduce torque.96␣
cold (2.5°C) sterile microcannula attached to the Endovac nega-
tive pressure irrigation system for 5 minutes. Recently different Preparation Errors
cryotherapy applications have also resulted in lower postoperative
pain levels (intracanal, intraoral, and extraoral).139␣ Regardless of the technique used in root canal preparation, proce-
dural errors can occur (see Chapter 18). These include loss of WL,
Ultrasonics apical transportation, apical perforation, instrument fracture, and
stripping perforations.
There are many uses of ultrasonics in root canal treatment; for Loss of WL has several causes, including failure to have an ade-
example, refinement of access cavity preparations for a more con- quate reference point from which the WL is determined, packing
servative approach, orifice location, pulp stone removal, removal tissue and debris in the apical portion of the canal, ledge forma-
of materials from the inside of the root canal (including posts, sep- tion, and inaccurate measurements of files.
arated instruments, silver cones), enhancing irrigation, thermo- The selection of an adequate coronal reference point is very
plastic obturation, and root-end preparation during surgery;140 important. Some clinicians advocate for using the same coronal
however, shaping curved root canals with ultrasonic instruments reference for all root canals in the same tooth to ease the proce-
has been shown to create preparation errors and is no longer dure; however, the proper determination of a straight and stable
recommended.141-143 reference localized in the original path of the instrument when
In terms of enhancing irrigation, agitation techniques allow an shaping each canal will avoid procedural mishaps during canal
irrigation solution to reach the apical third and irregularities in the preparation. Moreover, the more visible the reference point, the
root canal system, and hence improve cleaning efficiency. The use less stress for the rotary instrument when the clinician checks the
of ultrasonics,144 sonic devices,145 or apical negative pressure146 proper shaping length.
irrigation has been recommended. Many other devices or instru- On the other hand, the most predictable method to prevent
ments are continuously being marketed for further disinfection any kind of blockage in the apical portion of the canal is to regu-
of root canal system; however, cost-effectiveness still needs to be larly use the so-called patency file during cleaning and shaping
scientifically demonstrated. procedures. Not only does it minimize the risk of loss of length,
The main mechanism of adjunctive cleaning with ultrasonics is but it also reduces further mishaps occurring when trying to force
acoustic microstreaming,147 which is described as complex steady- an instrument to go back to the initial length.
state streaming patterns in vortex-like motions or eddy flows that And lastly, the reconfirmation of the WL electronically with an
are formed close to the instrument. Agitation of the irrigant with apex locator after preparation of the coronal third will also help to
an ultrasonically activated instrument after completion of clean- maintain the correct length during the whole shaping procedure.
ing and shaping has the benefit of increasing the effectiveness of Apical transportation and zipping occur when relatively inflex-
the solution.113,148-150␣ ible files are used to prepare curved canals. The restoring force of
the file (the tendency to return to the original straight shape of the
Lubricants file) exceeds the threshold for cutting dentin in a curved canal (Figs.
14.12 and 14.13).156 When this apical transportation continues
Lubricants facilitate manipulation of hand files during cleaning with larger and larger files, a “teardrop” shape develops, and apical
and shaping. They are an aid in initial canal negotiation, especially perforation can occur on the lateral root surface (see Fig. 14.12).
in small and constricted canals without taper. The use of lubricants Transportation in curved canals already begins with a No. 25 file.24
during negotiation helps to avoid pulp tissue blockage. Especially Enlargement of curved canals at the WL beyond a No. 25 file can be
in vital teeth, pulp tissue may block the root canal during negotia- done only when an adequate coronal flare is developed. Moreover,
tion. This type of blockage is difficult to bypass but very easy to when shaping a difficult root canal, the most challenge anatomy is
prevent by filling the pulp chamber with viscous lubricants that often located in the apical third. The potential of avoiding accidents
will enhance the advancement of the small file without apically in this delicate portion starts with a proper negotiation after remov-
pushing the pulp tissue remnants.151 ing the restrictive dentin in the coronal and middle third if the root
Glycerin is a mild alcohol that is inexpensive, nontoxic, aseptic, canal presents great curvatures or S-shaped root canals. Choosing
and somewhat soluble. A small amount can be placed along the flexible and resistant rotary instruments is very important not to
shaft of the file or deposited in the canal orifice. Counterclockwise deform the apical third of root canals with complicated anatomy.
As stated before, instrument fracture occurs with torsional and

cyclic fatigue. Locking the flutes of a file in the canal wall while
continuing to rotate the coronal portion of the instrument is an
example of torsional failure (Fig. 14.14). Conversely, cyclic fatigue
results when repetitive low-level strain develops in the metal. File
fracture occurs more frequently with rotaries but may also involve
hand instruments such as K-type and Hedström files.157
Working under the operating microscope, using specific ultra-
sonic tips and specifically designed armamentarium will help to
retrieve broken instruments from the root canal, but it is a dif-
ficult task and in most situations leads to a weakening of the tooth
caused by excessive removal of dentin, allowing the instrument
to disengage from the dentin and finding a path for the exit.
Therefore the best way to deal with instrument fracture is pre-
vention. To avoid NiTi rotary instruments separation some strate-
gies are recommended: optimal case selection; understanding the
A
#45 #40 #35 #30
Procedural errors of canal transportation, zipping, and strip

perforation occur during standardized preparation when files remove den-
tin from the outer canal wall apical to the curve and from the inner wall (A) No. 35 file fractured in the mesiobuccal canal. (B) Scanning
coronal to the curve. This is related to the restoring force (stiffness) of the electron microscope examination reveals torsional failure at the point of
files. Note in the apical portion the transportation takes the shape of a tear fracture. Note the tightening of the flutes near the fracture and the unwind-
drop as the larger files are used. ing of the flutes along the shaft.
A B
A typical procedural error in shaping of curved root canals is straightening or transportation.
A comparison of (A) preoperative and (B) postoperative radiographs in this case reveals that mesial and
distal canals have been transported, and there are apical perforations.
characteristics and limitations of the selected instrument; limiting root is not always centered in cross-sections; before preparation,
the use of instruments; prematurely eliminating coronal interfer- the average distance to the furcal wall (danger zone) is less than
ence before taking rotary instruments to the full root canal length; the distance to the bulky outer wall (safety zone). An additional
ensuring a correct glide path; using the instruments following complicating factor is the furcal concavity of the root.158␣
the recommended directions for use in terms of rotational speed,
torque, and motion; not forcing instruments in an apical direction
to avoid taper-lock; recapitulating if the instrument is not able to Preparation Techniques
advance in the root canal; and not inserting the instrument in the Working Length Determination
root canal if the active cutting surface of the instrument is blocked
with debris (use gauzes to clean the flutes).78 A major step in clinical endodontics, regardless of the instruments
Stripping perforations occur toward the furcal region of curved used, is the determination of the apical termination of cleaning
roots and frequently in the mesial roots of maxillary and mandib- and shaping, as well as obturation procedures. Using diagnostic
ular molars (Figs. 14.15 and 14.16). The canal in this area of the radiographs, an estimate of the WL can be obtained. With a staged
A B
(A) The furcal region of molars at the level of the curvature (danger zone) is a common site for
stripping perforation. (B) Note the concavity (arrows) in the furcation area of this mandibular molar.
A B
Straight-line access can result in stripping perforations in the furcal areas of molars. (A) The
use of large Gates-Glidden drills and overpreparation has resulted in the stripping perforation. (B) Note that
the perforation is in the concavity of the furcation.
preparation sequence as detailed before, initial files will not be Standardized Preparation
placed into the root canal as to reach WL, as their use is restricted After 1961 instruments were manufactured with a standard
to the coronal and middle thirds of the canal. However, during all formula. Clinicians utilized a preparation technique of sequen-
shaping stages care should be taken not to inadvertently overex- tially enlarging the canal space with smaller to larger instru-
tend the instruments. As soon as a small file appears to reach the ments at the WL.162 In theory, this created a standardized
estimated termination point, the use of an electronic apex loca- preparation of uniform taper. Unfortunately, in cylindrical and
tor is recommended. These units typically provide an accurate small curved canals, procedural errors were identified with the
assessment of the location of the narrowest canal diameter and technique (Box 14.2).163␣
can detect the position of the test file relative to the periodontal
ligament. Exposing a radiograph with the test file in place then Step-Back Technique
verifies the measurement. The step-back technique reduces procedural errors and
Based on this information clinicians may note the WL for this improves débridement.163,164 It involves that, after coronal
canal as the distance between a coronal reference point and the flaring, the apical canal diameter is determined with the IAF
apical termination point. Based on clinical evidence7,19 as well as (the first file that binds at WL). Subsequent preparation to WL
classic studies159 WL should terminate just short of the electroni- up to the master apical file (MAF) creates the apical prepara-
cally measured canal length. During canal preparation, WLs tend tion size, for example, size No. 35; the succeeding larger files
to shorten as a result of the fact that the enlarged canal provides are shortened by 0.5- or 1-mm increments from the previous
a straighter path to the apical termination point; however, this file length (Figs. 14.17 and 14.18) up to the final file (FF), for
effect is minimized with coronal flaring. Nevertheless, it is recom- example, size No. 60. This step-back process creates a flared,
mended to periodically check the WL and correct it if needed.␣ tapering preparation while reducing procedural errors. The
last file used in the step-back sequence becomes the FF. This
Hand Instrumentation type of preparation is superior to standardized serial filing and
reaming techniques in débridement and maintaining the canal
Watch Winding shape.164␣
Watch winding is reciprocating back and forth (clockwise/coun-
terclockwise) rotation of the instrument in an arch and is used Step-Down Technique
to negotiate canals and to work files to place. The first file that The step-down technique is advocated for cleaning and shaping
reaches tentative WL and slightly binds is called initial apical file procedures as it removes coronal interferences and provides coro-
(IAF). Light apical pressure is applied to move the file deeper into nal taper. Originally advocated for hand-file preparation,165 the
the canal.␣ step-down technique has been incorporated into those techniques
employing NiTi files. With the pulp chamber filled with irrig-
Reaming ant or lubricant, the canal is explored with a small instrument to
Reaming is defined as the clockwise cutting rotation of the file. assess morphology (curvature). The WL can be established at this
Generally, the instruments are placed into the canal until binding time. The coronal one third of the canal is then flared with Gates-
is encountered. The instrument is then rotated clockwise 180 to Glidden drills or NiTi orifice shapers. A large file (such as No. 60)
360 degrees to plane the walls and enlarge the canal space.␣ is then placed in the canal, and a watch-winding motion is used
until resistance is encountered.165 The process is repeated with
Filing sequentially smaller files until the apical portion of the canal is
Filing is defined as placing the file into the canal and pressing it
laterally while withdrawing it along the path of insertion to scrape
(plane) the wall. A modification is the quarter-turn-pull tech-
nique. This involves placing the file to the point of binding, rotat-
ing the instrument 90 degrees, and pulling the instrument along
the canal wall. Any filing technique has a tendency to straighten
curved canals.␣
Circumferential Filing
Circumferential filing is used for canals that are larger and/or not
round. The file is placed into the canal and withdrawn in a direc-
tional manner sequentially against the mesial, distal, buccal, and
lingual walls. Circumferential filing is not very effective beyond
the coronal third of a root canal.160,161␣
BOX 14.2
Working length (WL)

Initial apical file (IAF)
Master apical file (MAF)
Final file (FF) The step-back preparation is designed to provide a tapering
Final apical file (FAF) preparation. The process begins with one file size larger than the master
apical file with incremental shortening of either 0.5 or 1 mm.
A B
C D
E F
An example of step-back preparation in a moderately curved canal. (A) The No. 25 master
apical file at the corrected working length of 21 mm. (B) The step-back process begins with the No. 30
file at 20.5 mm. (C) No. 35 file at 20 mm. (D) No. 40 file at 19.5 mm. (E) No. 45 file at 19 mm. (F) No. 50
file at 18.5 mm.
G H
I
(G) No. 55 file at 18 mm. (H) No. 60 file at 17.5 mm. (I) No. 70 file at 17 mm.
reached. The WL and the IAF (the first file that binds at WL) can canal obstructions, and a gradual passive, slight enlargement of
be determined whether this was not accomplished initially. The the canal in an apical to coronal direction.␣
apical portion of the canal can now be prepared by enlarging the
canal to the MAF at the WL. Apical taper is accomplished using Anticurvature Filing
a step-back technique.␣ Anticurvature filing is advocated during coronal flaring pro-
cedures to preserve the furcal wall in the treatment of molars
Passive Step-Back Technique (Fig. 14.20). As stated before, canals are often not centered in
The passive step-back technique is a modification of the incre- mesial roots of maxillary and mandibular molars; instead, they
mental step-back technique.9,166 After the apical diameter of the are located closer to the furcation. Stripping perforations occur
canal has been determined, the next higher instrument is inserted primarily during use of the Gates-Glidden drills but also with
until it first makes contact (binding point). It is then rotated overzealous use of hand instruments. To prevent this procedural
one-half turn and removed (Fig. 14.19). The process is repeated error, the Gates-Glidden drills should be confined to the canal
with larger and larger instruments being placed to their binding space coronal to the root curvature and used in a step-back or
point. This entire instrument sequence is then repeated. With step-down manner (Figs. 14.21 and 14.22). Gates-Glidden
each sequence, the instruments drop deeper into the canal, creat- drills and laterally cutting NiTi orifice shapers can also be used
ing a tapered preparation. Advantages to the technique include directionally in an anticurvature fashion to selectively remove
knowledge of canal morphology, removal of debris and minor dentin from the bulky wall (safety zone) toward the line angle,
clockwise rotation is employed to evacuate the debris. The bal-

anced force concept is considered the most effective hand instru-
mentation technique.74,91␣
Recapitulation
Recapitulation is important regardless of the technique selected
(Fig. 14.23) and is accomplished by taking a small file to the WL
to loosen accumulated debris and then flushing it with 1 to 2
mL of irrigant. Recapitulation is performed between each succes-
sive enlarging instrument regardless of the cleaning and shaping
technique.␣
Shaping Modifications
The apical configuration in a given case may be recognized as an
apical stop, apical seat, or open apex. In addition to the assessment
of a diagnostic radiograph these configurations are detected by
placing the MAF to the corrected WL after shaping is completed.
If the MAF easily extends past WL, the apical configuration is
open. If the MAF stops at WL, a file one or two sizes smaller is
placed to the same depth. If this file stops as well, the apical con-
figuration is called an apical stop. When the smaller file goes past
Passive step-back. Smaller to larger files are inserted to their
the corrected WL, the apical configuration is a seat.
initial point of binding and then rotated 180 to 360 degrees and withdrawn.
This process creates slight taper and coronal space and permits larger
In a small curved canal, enlargement should be restricted to three
instruments to reach the apical one third. sizes larger than the IAF to decrease the potential for transportation.
In a straight canal, it may be larger without producing a procedural
error. Because a properly prepared canal exhibits taper, the small
files at the corrected WL can be used to enlarge the canal without
transportation. Additional apical enlargement is performed with an
irrigant in the canal and employs a reaming action at the corrected
WL. The last file used becomes the so-called final apical file (FAF).
Because this file is only contacting the apical portion of the canal,
the technique may result in a less irregular apical preparation. The
canal is then irrigated, the smear layer is removed with a decalcifying
agent, and the canal dried with paper points.␣
Engine-Driven Instruments
Gates-Glidden Drills
Gates-Glidden drills have been historically used to enlarge canal ori-
The anticurvature filing technique. Instruments are directed fices, preferably in pairs such as size Nos. 3 and 2 (diameters 0.7 and
away from the furcal danger zone toward the line angles (safety zone) 0.9 mm, respectively) (see Figs. 14.21 and 14.22). If the canal orifice
where the bulk of dentin is greater. cannot accommodate a No. 50 file, careful hand instrumentation
should be performed to provide adequate initial coronal space. To
protecting the inner or furcal wall (danger zone) coronal to the prevent stripping perforations, Gates-Glidden drills should not be
curve (see Fig. 14.20).␣ placed apical to canal curvatures. Moreover, with the advancement of
NiTi rotary instruments and the concept of minimally invasive endo-
Balanced Force Technique dontics, the use of Gates-Glidden drills should be reconsidered. The
The balanced force technique recognizes the fact that instruments amount of dentin removed in the coronal third makes Gates-Glidden
are guided by the canal walls when rotated.167 Because files with a drills an unsuitable instrument for modern endodontics.␣
symmetric cross-section will cut in both a clockwise and counter-
clockwise rotation, the balanced force concept of instrumentation NiTi Rotary Instruments
consists of placing the file to length and then a clockwise rotation As stated previously, NiTi rotary preparation is typically per-
(less than 180 degrees) engages dentin. This is followed by a coun- formed in a staged approach using coronal flaring; however, the
terclockwise rotation (at least 120 degrees) with apical pressure to specific technique is based on the instrument system selected. One
cut and enlarge the canal. The degree of apical pressure varies from instrument sequence uses NiTi files in a crown down approach,
light pressure with small instruments to heavy pressure with large with a constant taper and variable ISO tip sizes (Fig. 14.24). With
instruments. The clockwise rotation pulls the instrument into the this technique, a 0.06 taper is selected. Initially a size .06/45 file
canal in an apical direction. The counterclockwise cutting rotation is used until resistance, followed by the .06/40, .06/35, .06/30,
forces the file in a coronal direction while cutting circumferen- .06/25, and .06/20. In a second technique, NiTi files with a con-
tially. After the cutting rotation, the file is repositioned, and the stant tip diameter are used also in a crown down sequence. The
process is repeated until the WL is reached. At this point, a final initial file is a .10/20 instrument, the second a .08/20, the third
A B
C D
Straight-line access in a maxillary left first molar with Gates-Glidden drills used in a slow-speed
handpiece using a step-back technique. (A) The No. 1 Gates is used until resistance. (B) This is followed
by the No. 2, which should not go past the first curvature. (C) The No. 3 Gates is used 3 to 4 mm into the
canal (D) Followed by the No. 4 instrument.
a .06/20, and the fourth a .04/20 (see Fig. 14.24). Many varia- than higher rotational speed (e.g., 250 rpm). However, mar-
tions of these basic approaches have been recommended for dif- tensitic rotaries work better with higher speeds, for example,
ferent file designs. More recently introduced systems try to limit 500 rpm.169
the number of file sizes, up to the point of using only one size for Currently marketed electric motors have the torque setting
the majority of canals. Obviously, one size will not fit all canal already programmed. These settings are a reasonable protection
shapes, and modifications will frequently need to be made when against instrument breakage caused by torsional loading but are
such a system is used (Video 14.4). less effective with greater tapers, such as .06 and .08.38 All rotaries
Critical for all rotaries is the handling of these files. Besides work best in canals flooded with irrigation solution and not in the
manufacturer guidelines for individual files there are several presence of a gel-type lubricant such as RC Prep.96
general principles that should be followed.72,168 For exam- NiTi rotaries should not be placed into an unexplored canal
ple, instrument insertions should follow an in-and-out pat- but rather follow hand instruments. These hand instruments
tern; each instrumentation step should consist of three to five establish a glide path that then can be followed by rotaries.170 It is
movements and should not exceed 10 to 15 seconds. Apically important to note that hand files for glide path preparation should
directed force should typically not exceed the force required not be precurved; only then can rotaries predictably follow.
to bend the rotary when placed on a tabletop. Most NiTi files Frequently NiTi rotaries are combined with hand files or
are made of austenitic alloy and work best with lower rather other rotary instruments. One such combination technique
immediately be placed to the estimated WL and a WL radio-

graph can be obtained (see Fig. 14.25). For more constricted
canals, NiTi orifice modifiers can be used to accomplish early
coronal enlargement. This step facilitates irrigation and removes
coronal interferences, which in turn permits easier access to the
apical portion of the root canal and more accurate determina-
tion of apical constriction location171 as well as size.172
In the presence of irrigant or gel-based lubricant, the canal is
negotiated to full length with a hand file used in watch-winding
motion. If an impediment is felt, the negotiation files need to be
precurved. However, in order to secure a glide path for subsequent
rotary use, it must be confirmed that a straight small K-file (e.g.,
size No. 10 or 15) reaches the corrected WL. The tightness of
fit of the negotiation file at WL gives an estimate of the canal
size; however, coronal interferences do not permit a more accurate
assessment at this point.
Then, the middle and apical portions of the canal are prepared
using NiTi rotary instruments (see Figs. 14.24 and 14.25). Rotary
files are used with a crown-down approach to reach the corrected WL.
Using this approach with continuously tapered rotaries creates coro-
nal taper and reduces the contact area of the file so torsional forces are
A maxillary first molar following straight-line access with the reduced.173 Differently designed NiTi rotaries may follow a single-
Gates-Glidden drills. length principle, according to the manufacturers’ recommendations.
Emphasis has traditionally been placed on determining the
canal length with comparatively little consideration of the canal
diameter in the apical portion of the root. Because every canal is
unique in its morphology, apical canal diameters must be assessed.
After initial preparation to length the size of the apical portion of
the canal is determined by placing successively larger instruments
to the corrected WL until slight binding is encountered (Fig.
14.26). Often, the next larger instrument will not go to the cor-
rected WL. If it does go to length, a subjective estimation of the
apical diameter must be made depending on the degree of bind-
ing. This file will be the IAF (initial file to bind). It is defined as
the largest file to bind slightly at the corrected WL after straight-
line access. This file size provides an estimate of the canal diameter
before cleaning and shaping. A shaping target is set, the MAF,
which is the point where the step-back preparation begins. It
should be considered that this approach may underestimate actual
constriction diameters,174 and therefore additional apical enlarge-
ment may be reconsidered.
When the body of the canal has been shaped, the apical por-
tion may be additionally prepared using hand or rotary files
(Fig. 14.27). The first instrument selected for this portion of the
shaping process is one size larger than the MAF (estimated canal
diameter at WL). Recently, clinical evidence suggests that such an
enlargement may be beneficial for outcome.175
Regardless, NiTi instruments continue to evolve and shap-
ing with modern instruments that are more flexible allows
better preparations and respect to natural anatomies. First,
manufacturers focused on enhancing design characteristics
Recapitulation is accomplished between each instrument by such as different cross-sections, tip designs, and progres-
reaming with the master apical file or a smaller instrument, minimizing
sive tapers over the length of the cutting blades to improve
packing of debris and loss of length.
the properties of rotary instruments. Second, they suggested
reciprocation motions that seemed to enhance cyclic fatigue
utilizes the following steps: coronal flaring, NiTi rotary prepa- resistance. Third, proprietary thermal treatments optimized the
ration to WL, and additional apical enlargement (Box 14.3). mechanical properties of NiTi by improving its microstruc-
After access, the irrigated canal is explored with a No. 10 or ture through different series of heating and cooling treatments
15 K-file into the midroot area. Sometimes a canal is already (M-wire, CM-Wire, Blue and Gold alloys are some examples
naturally flared and wide, for example a maxillary central inci- of improved alloys). At the same time, manufacturers have also
sor or canine in a younger patient. Then a size No. 10 file may developed different manufacturing methods to the traditional
A B
C D
E F
The mesiobuccal canal is prepared using nickel-titanium rotary files using a crown-down tech-
nique. In this sequence, each instrument exhibits the same .06 taper with varied International Organization
for Standardization standardized tip diameters. Instruments were used to resistance. (A) The process
begins with a .06/45 file to resistance at 16.0 mm. (B) Followed by a .06/40 instrument at 17.0 mm. (C)
The .06/35 file is used to 18.0 mm. (D) The .06/30 at 19.0 mm. (E) The .06/25 at 20.0 mm. (F) The .06/20
file is to the corrected working length of 21.0 mm.
grinding method (twisting, shape-setting, and electric dis- nonround cross sections176 and also better respect coronal den-
charge machining are some examples). Taking advantage of tin compared with traditional rotaries.177␣
all these developments together, the last generation of rotary
instruments, the so-called 3D conforming instruments (as a Criteria for Evaluating Cleaning and Shaping
result of a characteristic nonflat morphology), better address
After cleaning and shaping procedures, the canal should
exhibit “glassy smooth” walls, and there should be no evi-
BOX 14.3 dence of dentin filings, debris, or irrigant in the canal. This
Canal exploration
can be directly determined in the coronal root canal portion
Coronal flaring when an operating microscope is used to visualize endodontic
Canal negotiation procedures; it can only be indirectly determined in the more
Working length determination apical portion of the root canal by tactile feedback during
Initial rotary preparation to WL instrumentation.
Master apical file determination Shaping is evaluated by assessing the canal taper and identify-
Additional apical enlargement ing the apical configuration in size and shape. For obturation with
lateral compaction, a small finger spreader should go ideally to
A B
C D
Nickel-titanium rotary files with a standardized International Organization for Standardization
tip diameter and variable tapered files can be used in canal preparation. In this sequence, the instru-
ments have a standardized tip diameter of .20 mm. (A) Initially a 1.0/.20 file is used. (B) This is followed
by .08/.20. (C) The third instrument is a .06/.20. (D) The final instrument is a .04/.20 file to the corrected
working length of 21 mm.
A B
C D
After straight-line access in this maxillary molar, the actual constriction size is determined by
successively placing small to larger files to the corrected working length. (A) No. 15 stainless steel file is
placed to 21.0 mm without resistance. (B) No. 20 is placed to 21.0 mm without resistance. (C) The No. 25
file reaches 21 mm with slight binding. (D) No. 30 file is then placed and does not go the corrected working
length, indicating the initial canal size in the apical portion of the canal is No. 25.
within 1 mm of the corrected WL without binding. For warm 5. Debris is loosened and dentin is removed from all walls on
vertical compaction, the plugger should reach to within 5 mm of the outstroke or with a rotating action at or close to WL.
the corrected WL (Fig. 14.28). 6. Instrument binding or dentin removal on insertion should
The following principles and concepts should be applied be avoided. Files are teased to length using a watch-wind-
regardless of the instruments or technique selected: ing action. This is a back-and-forth rotating motion of
1. Initial canal exploration is always performed with smaller the files between the thumb and forefinger, continually
hand files to gauge canal size, shape, and configuration. working the file apically. Careful file manipulation in an
2. Copious irrigation must be provided between instruments in irrigant-filled canal will help to avoid apical packing of
the canal. debris and minimize extrusion of debris into the perira-
3. Coronal preflaring will facilitate placing larger files to WL dicular tissues.
(either hand or rotary) and will reduce procedural errors such 7. Circumferential filing is used for canals that exhibit cross-
as loss of WL and canal transportation. sectional shapes that are not round. The file is placed into
4. Apical canal enlargement is gradual, using sequentially larger the canal and withdrawn in a directional manner against the
files, regardless of flaring technique. mesial, distal, buccal, and lingual walls.
A B
C D
Final apical enlargement. (A) The master apical file No. 25 at the corrected working length
of 21.0 mm. (B) Enlargement with a No. 30 file to the corrected working length of 21.0 mm. (C) Further
enlargement with a No. 35 file. (D) Final enlargement to a No. 40 file. The final instrument used becomes
the final apical file (FAF).
8. After each insertion the file is removed and the flutes are 11. Overenlargement of curved canals by files attempting to
cleaned of debris; the file can then be reinserted into the straighten themselves will to lead to procedural errors (see
canal to plane the next wall. Debris is removed from the file Fig. 14.12).
by wiping it with an alcohol-soaked gauze or a cotton roll.178 12. Overpreparation of canal walls toward the furcation may
9. Recapitulation is done to loosen debris by placing a result in a stripping perforation in the danger zone where
small-size file to the corrected WL followed by irrigation root dentin is thinner (see Fig. 14.13).
to mechanically remove the material. During recapitula- 13. Instruments, irrigants, debris, and obturating materials
tion, the canal walls are not planed, and the canal is not should be contained within the canal. These are all known
enlarged. physical or chemical irritants that will induce periradicular
10. Small, long, and curved canals are the most difficult and inflammation and may delay or compromise healing.
tedious to enlarge. They require extra caution during prepa- 14. Creation of an apical stop may be impossible if the api-
ration because they are the most prone to loss of length and cal foramen is already very large. An apical taper (seat) is
transportation. attempted but with care. Overusing large files aggravates the
A B
The coronal taper is assessed using the spreader or plugger depth of penetration. (A) With
lateral compaction, a finger spreader should fit loosely 1.0 mm from the corrected working length with
space adjacent to the spreader. (B) For warm vertical compaction, the plugger should go to within 5.0 mm
of the corrected working length.
problem by creating an even larger apical opening. A resis- BOX 14.4

tance form along the root canal should allow proper warm
vertical obturation with no need of an apical stop.
15. Forcing or locking (binding) files into dentin produces Calcium hydroxide
unwanted torsional force. This tends to untwist or “wrap up” Phenolics
and will weaken and break the instrument.␣ Aldehydes
Halides
Steroids
Intracanal Medicaments Antibiotics
Combinations
Intracanal medicaments have a long history of use as interim
appointment dressings. They have been employed for the following
three purposes: (1) to reduce interappointment pain, (2) to decrease
the bacterial count and prevent regrowth, and (3) to render the sterile water, to form a slurry; or as a proprietary paste supplied in
canal contents inert. Some common agents are listed in Box 14.4. a syringe (see Fig. 14.29). A lentulo spiral is effective and efficient
Clinical evidence of the effectiveness of these agents is mixed; this for placement.187-189 Spinning the paste into the canal by rotating
has led to increased interest in the efficacy of so-called single visit endo- a file counterclockwise and using an injection technique is not as
dontic therapy. There are only few prospective studies directly com- effective. It is important to place the material deeply and densely
paring these two treatment modalities, with a meta-analysis favoring for maximum effectiveness. To accomplish this, straight-line access
single-visit treatment.179 Two well-done clinical studies180,181 showed should be performed, and the apical portion of the canal prepared
remaining microorganisms in accessory anatomy and isthmi, but also to a No. 25 file or greater. Removal after placement is difficult,190
in the main canal, remaining after single visit treatment as well as in and this is especially true in the apical portion of the root.␣
the majority of the cases with calcium hydroxide placement.
Phenols and Aldehydes
Calcium Hydroxide The majority of these medicaments exhibit nonspecific action
One intracanal agent that is effective in inhibiting microbial growth and can destroy host tissues, as well as microbes.191-193 Histori-
in canals is calcium hydroxide.182 Calcium hydroxide has antimi- cally, it was thought that these agents were effective, although
crobial activity that is a result of the alkaline pH, and it may aid in their use was based on opinion and empiricism. The phe-
dissolving necrotic tissue remnants and bacteria and their byprod- nols and aldehydes are toxic, and the aldehydes are fixative
ucts.183-185 Interappointment calcium hydroxide in the canal agents.194,195 When placed in the radicular space, they have
demonstrates no pain-reduction effects.186 Calcium hydroxide access to the periradicular tissues and the systemic circula-
has been recommended for use in teeth with necrotic pulp tissue tion.196,197 Research has demonstrated that their clinical use is
and bacterial contamination. It probably has little benefit in teeth not justified.198-202 Clinical studies assessing the ability of these
with vital pulps. Calcium hydroxide should be placed as a pow- agents to prevent or control interappointment pain indicate
der mixed with a liquid such as local anesthetic solution, saline, or that they are not effective.203-206␣
A B
C D
Calcium hydroxide placement. (A) Calcium hydroxide mixed with glycerin to form a thick
paste. (B) Placement with a lentulo spiral. (C) Injection of a proprietary paste. (D) Compaction of calcium
hydroxide powder with a plugger.
Corticosteroids Chlorhexidine
Corticosteroids are antiinflammatory agents that have been Chlorhexidine has recently been advocated as an intracanal medica-
advocated for decreasing postoperative pain by suppressing ment.210,211 A 2% gel is recommended, which can be used alone in
inflammation. The use of corticosteroids as intracanal medica- gel form or mixed with calcium hydroxide. When used with calcium
ments may decrease lower-level postoperative pain in certain hydroxide, the antimicrobial activity is greater than when calcium
situations;207 however, evidence also suggests that they may hydroxide is mixed with saline,212 and periradicular healing in animal
be ineffective, particularly with greater pain levels.206 Cases of models appears to be enhanced.213 However, a recent randomized clini-
irreversible pulpitis and cases in which the patient is experienc- cal trial did not show that the combination of calcium hydroxide and
ing acute apical periodontitis are examples where steroid use 2% chlorhexidine was advantageous compared with single appointment
might be beneficial.207-209␣ treatment in cases with periapical lesions, after 1 year of observation.187
7. Ng YL, Mann V, Gulabivala K: A prospective study of the fac-

tors affecting outcomes of nonsurgical root canal treatment: part 1:
6. Although removal of the smear layer is not universally advocated before periapical health, Int Endod J 44(7):583, 2011.
root canal obturation, those advocating its removal cite the following 8. Allison DA, Weber CR, Walton RE: The influence of the method
rationale. of canal preparation on the quality of apical and coronal obtura-
a. Smear layer provides an improved seal of the canal during tion, J Endod 5(10):298, 1979.
obturation 9. Schilder H: Cleaning and shaping the root canal, Dent Clin North
b. The organic component of smear layer is antimicrobial Am 18(2):269, 1974.
c. Maintenance of the smear layer strengthens root structure 10. Wilcox LR, Roskelley C, Sutton T: The relationship of root canal
d. Smear layer may contain bacterial contaminants enlargement to finger-spreader induced vertical root fracture, J
7. NaOCl is effective in removing the smear layer. Endod 23(8):533, 1997.
a. True 11. Kuttler Y: Microscopic investigation of root apexes, J Am Dent
b. False Assoc 50(5):544, 1955.
8. Which of the following irrigants may reduce postoperative pain? 12. Dummer PMH, McGinn JH, Rees DG: The position and topogra-
a. NaOCl phy of the apical canal constriction and apical foramen, Int Endod
b. EDTA J 17(4):192, 1984.
c. Cold saline 13. Gutierrez JH, Aguayo P: Apical foraminal openings in human
d. Chlorhexidine teeth, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 79(6):769,
9. Select the method that is most effective in maintaining canal patency. 1995.
a. Radiographic root length determination 14. Malueg LA, Wilcox LR, Johnson W: Examination of external api-
b. Electronic root length determination cal root resorption with scanning electron microscopy, Oral Surg
c. Use of patency file Oral Med Oral Pathol Oral Radiol Endod 82(1):89, 1996.
d. Selection of correct reference point 15. Farzaneh M, Abitbol S, Friedman S: Treatment outcome in end-
10. Select the most commonly used intracanal medication placed when odontics: the Toronto study, Phases I and II: orthograde retreat-
endodontic treatment is not completed. ment, J Endod 30(9):627, 2004.
a. NaOCl 16. de Chevigny C, Dao TT, Basrani BR, et al.: Treatment outcome
b. Calcium hydroxide in endodontics: the Toronto study—phase 4: initial treatment, J
c. Phenolic products Endod 34(3):258, 2008.
d. Chlorhexidine 17. Schaeffer MA, White RR, Walton RA: Determining the optimal
obturation length: a meta-analysis of literature, J Endod 31(4):271,
2005.
18. Wu MK, Wesselink PR, Walton RE: Apical terminus location of
root canal treatment procedures, Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 89(1):99, 2000.
ANSWERS 19. Ricucci D, Russo J, Rutberg M, et al.: A prospective cohort study of
endodontic treatments of 1,369 root canals: results after 5 years, Oral
Answer Box 14 Surg Oral Med Oral Pathol Oral Radiol Endod 112(6):825, 2011.
1 b. Use of hand instrumentations 20. Nair PN: On the causes of persistent apical periodontitis: a review,
2 b. False Int Endod J 39(4):249, 2006.
3 d. All of the above
21. Siqueira Jr JF: Aetiology of root canal treatment failure: why well-
treated teeth can fail, Int Endod J 34(1), 2001.
4 a. True
22. Friedman S: Management of post-treatment endodontic disease: a
5 a. True current concept of case selection, Aust Endod J 26(3), 2000.
6 d. Smear layer may contain bacterial contaminants 23. Wu MK, Dummer PM, Wesselink PR: Consequences of and strate-
7 b. False gies to deal with residual post-treatment root canal infection, Int
8 c. Cold saline Endod J 39(5), 2006.
9 c. Use of patency file 24. Eldeeb ME, Boraas JC: The effect of different files on the prepara-
10 b. Calcium hydroxide tion shape of severely curved canals, Int Endod J 18(1):1, 1985.
25. Chow TW: Mechanical effectiveness of root canal irrigation, J
Endod 9(11):475, 1983.
26. Ram Z: Effectiveness of root canal irrigation, Oral Surg Oral Med
References Oral Pathol 44(2):306, 1977.
27. Salzgeber RM, Brilliant JD: An in vivo evaluation of the penetra-
1. Ingle JI: Endodontics, ed 5, London ON, 2002, BC Decker. tion of an irrigating solution in root canals, J Endod 3(10):394,
2. Sabeti MA, Nekofar M, Motahhary P, et al.: Healing of apical peri- 1977.
odontitis after endodontic treatment with and without obturation 28. Ørstavik D, Kerekes K, Molven O: Effects of extensive apical ream-
in dogs, J Endod 32(7):628, 2006. ing and calcium hydroxide dressing on bacterial infection during
3. Delivanis PD, Mattison GD, Mendel RW: The survivability of F43 treatment of apical periodontitis: a pilot study, Int Endod J 24(1):1,
strain of Streptococcus sanguis in root canals filled with gutta-percha 1991.
and Procosol cement, J Endod 9(10):407, 1983. 29. Dalton BC, Ørstavik D, Phillips C, et al.: Bacterial reduction with
4. Sedgley CM, Lennan SL, Applebe OK: Survival of Enterococcus nickel-titanium rotary instrumentation, J Endod 24(11):763, 1998.
faecalis in root canals ex vivo, Int Endod J 38(10):735, 2005. 30. Sjögren U, Figdor D, Spångberg L, Sundqvist G: The antimicrobial
5. Landys Boren D, Jonasson P, Kvist T: Long-term survival of end- effect of calcium hydroxide as a short-term intracanal dressing, Int
odontically treated teeth at a public dental specialist clinic, J Endod Endod J 24(3):119, 1991.
41(2), 2015. 31. Wu YN, Shi JN, Huang LZ, Xu YY: Variables affecting electronic
6. Salehrabi R, Rotstein I: Endodontic treatment outcomes in a large root canal measurement, Int Endod J 25(2):88, 1992.
patient population in the USA: an epidemiological study, J Endod 32. Haapasalo M, Shen Y, Qian W, Gao Y: Irrigation in endodontics,
30(12), 2004. Dent Clin North Am 54(2), 2010.
33. Sluis LW vd, Versluis M, Wesselink PR: Passive ultrasonic irrigation 56. Reeh ES, Messer HH: Long-term paresthesia following inadvertent
of the root canal: a review of the literature, Int Endod J 40(6):415, forcing of sodium hypochlorite through perforation in maxillary
2007. incisor, Endod Dent Traumatol 5(4):200, 1989.
34. Usman N, Baumgartner JC, Marshall JG: Influence of instrument 57. Witton R, Brennan PA: Severe tissue damage and neurological defi-
size on root canal debridement, J Endod 30(2):110, 2004. cit following extravasation of sodium hypochlorite solution during
35. Rollison S, Barnett F, Stevens RH: Efficacy of bacterial removal routine endodontic treatment, Br Dent J 198(12):749, 2005.
from instrumented root canals in vitro related to instrumentation 58. Brown DC, Moore BK, Brown Jr CE, Newton CW: An in vitro
technique and size, Oral Surg Oral Med Oral Pathol Oral Radiol study of apical extrusion of sodium hypochlorite during endodon-
Endod 94(3):366, 2002. tic canal preparation, J Endod 21(12):587, 1995.
36. Card SJ, Sigurdsson A, Ørstavik D, Trope M: The effectiveness 59. Hülsmann M, Hahn W: Complications during root canal irri-
of increased apical enlargement in reducing intracanal bacteria, J gation-literature review and case reports, Int Endod J 33(3):186,
Endod 28(11):779, 2002. 2000.
37. Pettiette MT, Delano EO, Trope M: Evaluation of success rate of 60. Yamada RS, Armas A, Goldman M, Lin PS: A scanning electron
endodontic treatment performed by students with stainless-steel microscopic comparison of a high volume final flush with several
K-files and nickel-titanium hand files, J Endod 27(2):124, 2001. irrigating solutions: part 3, J Endod 9(4):137, 1983.
38. Peters OA: Current challenges and concepts in the preparation of 61. Lambrianidis T, Tosounidou E, Tzoanopoulou M: The effect
root canal systems: a review, J Endod 30, 2004. of maintaining apical patency on periapical extrusion, J Endod
39. Paqué F, Boessler C, Zehnder M: Accumulated hard tissue debris 27(11):696, 2001.
levels in mesial roots of mandibular molars after sequential irriga- 62. Holland R, Sant’Anna Junior A, Souza V, et al.: Influence of apical
tion steps, Int Endod J 44(2):148, 2011. patency and filling material on healing process of dogs’ teeth with
40. Love RM, Jenkinson HF: Invasion of dentinal tubules by oral bac- vital pulp after root canal therapy, Braz Dent J 16(1), 2005.
teria, Crit Rev Oral Biol Med 13(2):171, 2002. 63. Izu KH, Thomas SJ, Zhang P, et al.: Effectiveness of sodium hypo-
41. Akpata ES: Effect of endodontic procedures on the popula- chlorite in preventing inoculation of periapical tissue with contami-
tion of viable microorganisms in the infected root canal, J Endod nated patency files, J Endod 30(2):92, 2004.
2(12):369, 1976. 64. Vera J, Arias A, Romero M: Dynamic movement of intracanal gas bub-
42. Matsuo T, Shirakami T, Ozaki K, et al.: An immunohistological bles during cleaning and shaping procedures: the effect of maintaining
study of the localization of bacteria invading root pulpal walls of apical patency on their presence in the middle and cervical thirds of
teeth with periapical lesions, J Endod 29(3):194, 2003. human root canals-an in vivo study, J Endod 38(2):200, 2012.
43. Peters LB, Wesselink PR, Buijs JF, van Winkelhoff AJ: Viable bac- 65. Cailleteau JG, Mullaney TP: Prevalence of teaching apical patency
teria in root dentinal tubules of teeth with apical periodontitis, J and various instrumentation and obturation techniques in United
Endod 27(2):76, 2001. States dental schools, J Endod 23(6), 1997.
44. Bird DC, Chambers D, Peters OA: Usage parameters of nickel- 66. Flanders DH: Endodontic patency. How to get it. How to keep it.
titanium rotary instruments: a survey of endodontists in the United Why it is so important, N Y State Dent J 68(3), 2002.
States, J Endod 35(9):1193, 2009. 67. Buchanan LS: Management of the curved root canal, J Calif Dent
45. Parashos P, Messer HH: Uptake of rotary NiTi technology within Assoc 17(4), 1989.
Australia, Aust Dent J 50(4):251, 2005. 68. Carr GB, Schwartz RS, Schaudinn C, et al.: Ultrastructural exami-
46. Bjørndal L, Reit C: The adoption of new endodontic technology nation of failed molar retreatment with secondary apical periodon-
amongst Danish general dental practitioners, Int Endod J 38(1):52, titis: an examination of endodontic biofilms in an endodontic
2005. retreatment failure, J Endod 35(9):1303, 2009.
47. Waltimo T, Trope M, Haapasalo M, Ørstavik D: Clinical efficacy 69. Zhu WC, Gyamfi J, Niu LN, et al.: Anatomy of sodium hypochlo-
of treatment procedures in endodontic infection control and rite accidents involving facial ecchymosis - a review, J Dent 41(11),
one year follow-up of periapical healing, J Endod 31(12):863, 2013.
2005. 70. Yaylali IE, Demirci GK, Kurnaz S, et al.: Does maintaining api-
48. Shuping GB, Ørstavik D, Sigurdsson A, Trope M: Reduction of cal patency during instrumentation increase postoperative pain or
intracanal bacteria using nickel-titanium rotary instrumentation flare-up rate after non-surgical root canal treatment? A systematic
and various medications, J Endod 26(12):751, 2000. review of randomized controlled trials, J Endod epub ahead of
49. Siqueira JF, Lima KC, Magalhaes FAC, et al.: Mechanical reduc- print, 2018.
tion of the bacterial population in the root canal by three instru- 71. AAE: Endodontic case difficulty assessment form and guidelines. In
mentation techniques, J Endod 25(5):332, 1999. AAE, editor. Chicago, IL, 2010, American Association of End-
50. Siqueira Jr JF, Rocas IN, Santos SR, et al.: Efficacy of instrumenta- odontics.
tion techniques and irrigation regimens in reducing the bacterial 72. Peters OA, Paqué F: Current developments in rotary root canal
population within root canals, J Endod 28(3):181, 2002. instrument technology and clinical use: a review, Quintessence Int
51. de Gregorio C, Arias A, Navarrete N, et al.: Differences in disinfec- 41(6):479, 2010.
tion protocols for root canal treatments between general dentists 73. Walia H, Brantley WA, Gerstein H: An initial investigation of the
and endodontists: a Web-based survey, J Am Dent Assoc 146(7), bending and torsional properties of nitinol root canal files, J Endod
2015. 14(7):346, 1988.
52. Tanomaru Filho M, Leonardo MR, da Silva LA: Effect of irrigating 74. Peters OA, Schönenberger K, Laib A: Effects of four NiTi prepara-
solution and calcium hydroxide root canal dressing on the repair of tion techniques on root canal geometry assessed by micro com-
apical and periapical tissues of teeth with periapical lesion, J Endod puted tomography, Int Endod J 34, 2001.
28(4):295, 2002. 75. McSpadden JT, Bonaccorso A, Tocchio C, et al.: The zone tech-
53. Ørstavik D, Haapasalo M: Disinfection by endodontic irrigants nique, ENDO (Lond Engl) 2(1):33, 2008.
and dressings of experimentally infected dentinal tubules, Endod 76. Clark D, Khademi JA: Case studies in modern molar endodon-
Dent Traumatol 6(4):142, 1990. tic access and directed dentin conservation, Dent Clin North Am
54. Gernhardt CR, Eppendorf K, Kozlowski A, Brandt M: Toxicity of 54(2), 2010.
concentrated sodium hypochlorite used as an endodontic irrigant, 77. Bonessio N, Arias A, Lomiento G, Peters OA: Effect of root canal
Int Endod J 37(4):272, 2004. treatment procedures with a novel rotary nickel titanium instru-
55. Pashley EL, Birdsong NL, Bowman K, Pashley DH: Cytotoxic ment (TRUShape) on stress in mandibular molars: a comparative
effects of NaOCl on vital tissue, J Endod 11(12):525, 1985. finite element analysis, Odontology 105(1), 2017.
78. Peters OA: The guidebook to molar endodontics, 2016. Heidel- 102. Oncag O, Hosgor M, Hilmioglu S, et al.: Comparison of antibac-
berg, Germany, pp. 2016. terial and toxic effects of various root canal irrigants, Int Endod J
79. Pruett JP, Clement DJ, Carnes DL: Cyclic fatigue testing of nickel- 36(6):423, 2003.
titanium endodontic instruments, J Endod 23(2):77, 1997. 103. Abou-Rass M, Piccinino MV: The effectiveness of four clinical irri-
80. Zuolo ML, Walton RE: Instrument deterioration with usage: gation methods on the removal of root canal debris, Oral Surg Oral
nickel-titanium versus stainless steel, Quintessence Int 28(6):397, Med Oral Pathol 54(3):323, 1982.
1997. 104. Ballal NV, Mala K, Bhat KS: Effect of maleic acid and ethylenedi-
81. Torabinejad M, Handysides R, Khademi AA, Bakland LK: Clinical aminetetraacetic acid on the dissolution of human pulp tissue—an
implications of the smear layer in endodontics: a review, Oral Surg in vitro study, Int Endod J 44(4), 2011.
Oral Med Oral Pathol Oral Radiol Endod 94(6):658, 2002. 105. Hülsmann M, Heckendorff M, Lennon A: Chelating agents in root
82. McComb D, Smith DC: A preliminary scanning electron micro- canal treatment: mode of action and indications for their use, Int
scopic study of root canals after endodontic procedures, J Endod Endod J 36(12):810, 2003.
1(7):238, 1975. 106. Rossi-Fedele G, Dogramaci EJ, Guastalli AR, et al.: Antagonistic
83. Sen BH, Piskin B, Baran N: The effect of tubular penetration of interactions between sodium hypochlorite, chlorhexidine, EDTA,
root canal sealers on dye microleakage, Int Endod J 29(1):23, 1996. and citric acid, J Endod 38(4), 2012.
84. Chailertvanitkul P, Saunders WP, MacKenzie D: The effect of 107. Zehnder M, Schmidlin P, Sener B, Waltimo T: Chelation in root
smear layer on microbial coronal leakage of gutta-percha root fill- canal therapy reconsidered, J Endod 31(11), 2005.
ings, Int Endod J 29(4):242, 1996. 108. Baumgartner JC, Mader CL: A scanning electron microscope evalu-
85. Clark-Holke D, Drake D, Walton R, et al.: Bacterial penetration ation of four root canal irrigation regimes, J Endod 13(4):147, 1987.
through canals of endodontically treated teeth in the presence or 109. Mai S, Kim YK, Arola DD, et al.: Differential aggressiveness of
absence of the smear layer, J Dent 31(4):275, 2003. ethylenediamine tetraacetic acid in causing canal wall erosion in the
86. Oksan T, Aktener BO, Sen BH, Tezel H: The penetration of root presence of sodium hypochlorite, J Dent 38(3):201, 2010.
canal sealers into dentinal tubules. A scanning electron microscopic 110. Guignes P, Faure J, Maurette A: Relationship between endodontic
study, Int Endod J 26(5):301, 1993. preparations and human dentin permeability measured in situ, J
87. Wennberg A, Ørstavik D: Adhesion of root canal sealers to bovine Endod 22(2):60, 1996.
dentine and gutta-percha, Int Endod J 23(1):13, 1990. 111. Hottel TL, El-Rafai NY, Jones JJ: A comparison of the effects of
88. Leonard JE, Gutmann JL, Guo IY: Apical and coronal seal of roots three chelating agents on the root canals of extracted human teeth,
obturated with a dentine bonding agent and resin, Int Endod J J Endod 25(11):716, 1999.
29(2):76, 1996. 112. Lim TS, Wee TY, Choi MY, et al.: Light and scanning electron
89. Kokkas AB, Boutsioukis A, Vassiliades LP, Stavrianos CK: The microscopic evaluation of Glyde File Prep in smear layer removal,
influence of the smear layer on dentinal tubule penetration depth Int Endod J 36(5):336, 2003.
by three different root canal sealers: an in vitro study, J Endod 113. Krell KV, Johnson RJ: Irrigation patterns of ultrasonic endodontic
30(2):100, 2004. files. Part II. Diamond coated files, J Endod 14(2):535, 1988.
90. Cobankara FK, Adanr N, Belli S: Evaluation of the influence of 114. Mjør IA, Smith MR, Ferrari M, Mannocci F: The structure of den-
smear layer on the apical and coronal sealing ability of two sealers, tine in the apical region of human teeth, Int Endod J 34(5):346,
J Endod 30(6):406, 2004. 2001.
91. Siqueira Jr JF, Araujo MC, Garcia PF, et al.: Histological evalu- 115. Paqué F, Luder HU, Sener B, Zehnder M: Tubular sclerosis rather
ation of the effectiveness of five instrumentation techniques for than the smear layer impedes dye penetration into the dentine of
cleaning the apical third of root canals, J Endod 23(8), 1997. endodontically instrumented root canals, Int Endod J 39(1):18,
92. Wu MK, Wesselink PR: Efficacy of three techniques in cleaning 2006.
the apical portion of curved root canals, Oral Surg Oral Med Oral 116. Scelza MF, Teixeira AM, Scelza P: Decalcifying effect of EDTA-T,
Pathol Oral Radiol Endod 79(4):492, 1995. 10% citric acid, and 17% EDTA on root canal dentin, Oral Surg
93. Tan BT, Messer HH: The quality of apical canal preparation using Oral Med Oral Pathol Oral Radiol Endod 95(2):234, 2003.
hand and rotary instruments with specific criteria for enlargement 117. Calt S, Serper A: Smear layer removal by EGTA, J Endod 26(8):459,
based on initial apical file size, J Endod 28(9):658, 2002. 2000.
94. Rosenfeld EF, James GA, Burch BS: Vital pulp tissue response to 118. Haznedaroglu F: Efficacy of various concentrations of citric acid
sodium hypochlorite, J Endod 4(5):140, 1978. at different pH values for smear layer removal, Oral Surg Oral Med
95. Svec TA, Harrison JW: Chemomechanical removal of pulpal and Oral Pathol Oral Radiol Endod 96(3):340, 2003.
dentinal debris with sodium hypochlorite and hydrogen peroxide 119. Baumgartner JC, Brown CM, Mader CL, et al.: A scanning elec-
vs normal saline solution, J Endod 3(2):49, 1977. tron microscopic evaluation of root canal debridement using saline,
96. Peters OA, Boessler C, Zehnder M: Effect of liquid and paste-type sodium hypochlorite, and citric acid, J Endod 10(11):525, 1984.
lubricants on torque values during simulated rotary root canal 120. Rosenthal S, Spångberg L, Safavi K: Chlorhexidine substantivity
instrumentation, Int Endod J 38(1):223, 2005. in root canal dentin, Oral Surg Oral Med Oral Pathol Oral Radiol
97. Jungbluth H, Peters C, Peters OA, Zehnder M: Physicochemical Endod 98(4):488, 2004.
and pulp tissue dissolution properties of some household bleach 121. Jeansonne MJ, White RR: A comparison of 2.0% chlorhexidine
brands compared with a dental sodium hypochlorite solution, J gluconate and 5.25% sodium hypochlorite as antimicrobial end-
Endod 38(3):372, 2012. odontic irrigants, J Endod 20(6):276, 1994.
98. Zehnder M: Root canal irrigants, J Endod 32(5):389, 2006. 122. Kuruvilla JR, Kamath MP: Antimicrobial activity of 2.5% sodium
99. Zehnder M, Kosicki D, Luder H, et al.: Tissue-dissolving capac- hypochlorite and 0.2% chlorhexidine gluconate separately and
ity and antibacterial effect of buffered and unbuffered hypochlorite combined, as endodontic irrigants, J Endod 24(7):472, 1998.
solutions, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 94(6), 123. Vahdaty A, Pitt Ford TR, Wilson RF: Efficacy of chlorhexidine
2002. in disinfecting dentinal tubules in vitro, Endod Dent Traumatol
100. Berutti E, Marini R: A scanning electron microscopic evaluation 9(6):243, 1993.
of the debridement capability of sodium hypochlorite at different 124. White RR, Hays GL, Janer LR: Residual antimicrobial activity
temperatures, J Endod 22(9):467, 1996. after canal irrigation with chlorhexidine, J Endod 23(4):229, 1997.
101. Gambarini G, De Luca M, Gerosa R: Chemical stability of heated 125. Basrani BR, Manek S, Sodhi RN, et al.: Interaction between
sodium hypochlorite endodontic irrigants, J Endod 24(6):432, sodium hypochlorite and chlorhexidine gluconate, J Endod 33(8),
1998. 2007.
126. Torabinejad M, Khademi AA, Babagoli J, et al.: A new solution for 149. Archer R, Reader A, Nist R, et al.: An in vivo evaluation of the
the removal of the smear layer, J Endod 29(3):170, 2003. efficacy of ultrasound after step-back preparation in mandibular
127. Torabinejad M, Cho Y, Khademi AA, et al.: The effect of various molars, J Endod 18(11):549, 1992.
concentrations of sodium hypochlorite on the ability of MTAD to 150. Weller RN, Brady JM, Bernier WE: Efficacy of ultrasonic cleaning,
remove the smear layer, J Endod 29(4):233, 2003. J Endod 6(9):740, 1980.
128. Shabahang S, Pouresmail M, Torabinejad M: In vitro antimicrobial 151. Buchanan LS: The standardized-taper root canal preparation—part
efficacy of MTAD and sodium hypochlorite, J Endod 29(7):450, 6. GT file technique in abruptly curved canals, Int Endod J 34(3),
2003. 2001.
129. Shabahang S, Torabinejad M: Effect of MTAD on Enterococcus 152. Steinberg D, Abid-el-Raziq D, Heling I: In vitro antibacterial effect
faecalis-contaminated root canals of extracted human teeth, J Endod of RC-Prep components on Streptococcus sobrinus, Endod Dent
29(9):576, 2003. Traumatol 15(4):171, 1999.
130. Zhang B, Alysandratos KD, Angelidou A, et al.: Human mast cell 153. Zehnder M, Schmidlin PR, Sener B, Waltimo TM: Chelation in
degranulation and preformed TNF secretion require mitochondrial root canal therapy reconsidered, J Endod 31(11):817, 2005.
translocation to exocytosis sites: relevance to atopic dermatitis, J 154. Cehreli ZC, Onur MA, Tasman F, et al.: Effects of current and
Allergy Clin Immunol 127(6):1522, 2011. potential dental etchants on nerve compound action potentials, J
131. Machnick TK, Torabinejad M, Munoz CA, Shabahang S: Effect Endod 28(3):149, 2002.
of MTAD on the bond strength to enamel and dentin, J Endod 155. Goldberg F, Abramovich A: Analysis of the effect of EDTAC on
29(12):818, 2003. the dentinal walls of the root canal, J Endod 3(3):101, 1977.
132. Malkhassian G, Manzur AJ, Legner M, et al.: Antibacterial efficacy 156. Powell SE, Wong PD, Simon JH: A comparison of the effect of
of MTAD final rinse and two percent chlorhexidine gel medication modified and nonmodified instrument tips on apical canal configu-
in teeth with apical periodontitis: a randomized double-blinded ration. Part II, J Endod 14(5):224, 1988.
clinical trial, J Endod 35(11):1483, 2009. 157. Parashos P, Messer HH: Rotary NiTi instrument fracture and its
133. Stojic S, Shen Y, Qian W, et al.: Antibacterial and smear layer consequences, J Endod 32(11):1031, 2006.
removal ability of a novel irrigant, QMiX, J Endod 45(4), 2012. 158. Degerness RA, Bowles WR: Dimension, anatomy and morphology
134. Dai L, Khechen K, Khan S, et al.: The effect of QMix, an experi- of the mesiobuccal root canal system in maxillary molars, J Endod
mental antibacterial root canal irrigant, on removal of canal wall 36(6):985, 2010.
smear layer and debris, J Endod 37(1):80, 2011. 159. Sjögren U, Hagglund B, Sundqvist G, Wing K: Factors affecting
135. Wang Z, Shen Y, Haapasalo M: Effectiveness of endodontic dis- the long-term results of endodontic treatment, J Endod 16(10):498,
infecting solutions against young and old Enterococcus faecalis bio- 1990.
films in dentin canals, J Endod 38(10):1376, 2012. 160. Wu MK, Sluis LW vd, Wesselink PR: The capability of two hand
136. Morgental RD, Singh A, Sappal H, et al.: Dentin inhibits the anti- instrumentation techniques to remove the inner layer of dentine in
bacterial effect of new and conventional endodontic irrigants, J oval canals, Int Endod J 36(3):218, 2003.
Endod 39 (in press), 2013. 161. Paqué F, Balmer M, Attin T, Peters OA: Preparation of oval-
137. Ordinola-Zapata R, Bramante CM, Brandao Garcia R, et al.: The shaped root canals in mandibular molars using nickel-titanium
antimicrobial effect of new and conventional endodontic irrigants rotary instruments: a micro-computed tomography study, J Endod
on intra-orally infected dentin, Acta Odont Scand epub ahead of 36(4):703, 2010.
print, 2012. 162. Ingle JI: A standardized endodontic technique using newly devel-
138. Vera J, Ochoa J, Romero M, et al.: Intracanal cryotherapy reduces opment instruments and filling materials, Oral Surg Oral Med Oral
postoperative pain in teeth with symptomatic apical periodontitis: Pathol 14(1):83, 1961.
a randomized multicenter clinical trial, J Endod 44(1), 2018. 163. Weine FS, Kelly RF, Lio PJ: The effect of preparation procedures
139. Gundogdu EC, Arslan H: Effects of various cryotherapy applica- on original canal shape and on apical foramen shape, J Endod
tions on postoperative pain in molar teeth with symptomatic apical 1(8):255–262, 1975.
periodontitis: a preliminary randomized prospective clinical trial, J 164. Walton RE: Histologic evaluation of different methods of enlarging
Endod 44(3), 2018. the pulp canal space, J Endod 2(10):304, 1976.
140. Plotino G, Pameijer CH, Grande NM, Somma F: Ultrasonics in 165. Morgan LF, Montgomery S: An evaluation of the crown-down
endodontics: a review of the literature, J Endod 33(2), 2007. pressureless technique, J Endod 10(10):491, 1984.
141. Cymerman JJ, Jerome LA, Moodnik RM: A scanning electron 166. Torabinejad M: Passive step-back technique, Oral Surg Oral Med
microscope study comparing the efficacy of hand instrumenta- Oral Pathol 77(4):398, 1994.
tion with ultrasonic instrumentation of the root canal, J Endod 167. Roane JB, Sabala CL, Duncanson Jr MG: The “balanced force” con-
9(8):327, 1983. cept for instrumentation of curved canals, J Endod 11(5):203, 1985.
142. Schulz-Bongert U, Weine FS, Schulz-Bongert J: Preparation of 168. AAE: AAE: Rotary instrumentation: an endodontic perspective, Chi-
curved canals using a combined hand-filing, ultrasonic technique, cago, IL, 2008, American Association of Endodontics.
Comp Cont Educ Dent 16(3):270, 1995. 169. Bardsley S, Peters CI, Peters OA: The effect of three rotational
143. Chenail BL, Teplitsky PE: Endosonics in curved root canals. Part speed settings on torque and apical force with vortex rotary instru-
II, J Endod 14(5):214, 1988. ments in vitro, J Endod 37(6):860, 2011.
144. Gutarts R, Nusstein J, Reader A, Beck M: In vivo debridement effi- 170. Patino PV, Biedma BM, Liebana CR, et al.: The influence of a
cacy of ultrasonic irrigation following hand-rotary instrumentation manual glide path on the separation rate of NiTi rotary instru-
in human mandibular molars, J Endod 31(3), 2005. ments, J Endod 31(2):114, 2005.
145. Cheung GS, Stock CJ: In vitro cleaning ability of root canal irrig- 171. Stabholz A, Rotstein I, Torabinejad M: Effect of preflaring on tac-
ants with and without endosonics, Int Endod J 26(6), 1993. tile detection of the apical constriction, J Endod 21(2):92, 1995.
146. Nielsen BA, Craig Baumgartner J: Comparison of the EndoVac sys- 172. Pecora JD, Capelli A, Guersoli A, et al.: Influence of cervical preflar-
tem to needle irrigation of root canals, J Endod 33(5), 2007. ing on apical file size determination, Int Endod J 38(7):430, 2005.
147. Ahmad M, Pitt Ford TJ, Crum LA: Ultrasonic debridement of root 173. Schrader C, Peters OA: Analysis of torque and force with differently
canals: acoustic streaming and its possible role, J Endod 13(10):490, tapered rotary endodontic instruments in vitro, J Endod 31(2):120,
1987. 2005.
148. Cameron JA: The use of ultrasonics in the removal of the smear 174. Paqué F, Zehnder M, Marending M: Apical fit of initial K-files
layer: a scanning electron microscope study, J Endod 9(7):289, in maxillary molars assessed by micro-computed tomography, Int
1983. Endod J 43(4):328, 2010.
175. Saini HR, Tewari S, Sangwan P, et al.: Effect of different apical 194. Harrison JW, Bellizzi R, Osetek EM: The clinical toxicity of end-
preparation sizes on outcome of primary endodontic treatment: a odontic medicaments, J Endod 5(2):42, 1979.
randomized controlled trial, J Endod 38(10):1309, 2012. 195. Thoden van Velzen SK, Feltkamp-Vroom TM: Immunologic con-
176. Arias A, Paque F, Shyn S, et al.: Effect of canal preparation with sequences of formaldehyde fixation of autologous tissue implants, J
TRUShape and Vortex rotary instruments on three-dimensional Endod 3(5):179, 1977.
geometry of oval root canals, Aust Endod J 44(1), 2018. 196. Walton RE, Langeland K: Migration of materials in the dental pulp
177. Peters OA, Arias A, Paque F: A micro-computed tomographic of monkeys, J Endod 4(6):167, 1978.
assessment of root canal preparation with a novel instrument, 197. Myers DR, Shoaf HK, Dirksen TR, et al.: Distribution of
TRUShape, in mesial roots of mandibular molars, J Endod 41(9), 14C-formaldehyde after pulpotomy with formocresol, J Am Dent
2015. Assoc 96(5):805, 1978.
178. Ferreira Murgel CA, Walton RE, Rittman B, Pecora JD: A compar- 198. Doran MG, Radtke PK: A review of endodontic medicaments, Gen
ison of techniques for cleaning endodontic files after usage: a quan- Dent 46(5):484, 1998.
titative scanning electron microscopic study, J Endod 16(5):214, 199. Harrison JW, Baumgartner JC, Svec TA: Incidence of pain associ-
1990. ated with clinical factors during and after root canal therapy. Part
179. Sathorn C, Parashos P, Messer HH: Effectiveness of single- versus 1. Interappointment pain, J Endod 9(9):384, 1983.
multiple-visit endodontic treatment of teeth with apical periodon- 200. Byström A, Claesson R, Sundqvist G: The antibacterial effect of
titis: a systematic review and meta-analysis, Int Endod J 38(6):347, camphorated paramonochlorophenol, camphorated phenol and
2005. calcium hydroxide in the treatment of infected root canals, Endod
180. Nair PN, Henry S, Cano V, Vera J: Microbial status of apical root Dent Traumatol 1(5):170, 1985.
canal system of human mandibular first molars with primary apical 201. Walton RE: Intracanal medicaments, Dent Clin North Am
periodontitis after “one-visit” endodontic treatment, Oral Surg Oral 28(4):783, 1984.
Med Oral Pathol Oral Radiol Endod 99(2), 2005. 202. Harrison JW, Baumgartner CJ, Zielke DR: Analysis of interap-
181. Vera J, Siqueira JF, Ricucci D, et al.: One- versus two-visit end- pointment pain associated with the combined use of endodontic
odontic treatment of teeth with apical periodontitis: a histobacte- irrigants and medicaments, J Endod 7(6):272, 1981.
riologic study, J Endod 38(8):1040, 2012. 203. Maddox DL, Walton RE, Davis CO: Incidence of post-treatment
182. Law A, Messer H: An evidence-based analysis of the antibacte- endodontic pain related to medicaments and other factors, J Endod
rial effectiveness of intracanal medicaments, J Endod 30(10):689, 3(12):447, 1977.
2004. 204. Kleier DJ, Mullaney TP: Effects of formocresol on posttreatment
183. Yang SF, Rivera EM, Baumgardner KR, et al.: Anaerobic tissue- pain of endodontic origin in vital molars, J Endod 6(5):566, 1980.
dissolving abilities of calcium hydroxide and sodium hypochlorite, 205. Torabinejad M, Kettering JD, McGraw JC, et al.: Factors associ-
J Endod 21(12):613, 1995. ated with endodontic interappointment emergencies of teeth with
184. Safavi KE, Nichols FC: Effect of calcium hydroxide on bacterial necrotic pulps, J Endod 14(5):261, 1988.
lipopolysaccharide, J Endod 19(2):76, 1993. 206. Trope M: Relationship of intracanal medicaments to endodontic
185. Safavi KE, Nichols FC: Alteration of biological properties of bacte- flare-ups, Endod Dent Traumatol 6(5):226, 1990.
rial lipopolysaccharide by calcium hydroxide treatment, J Endod 207. Ehrmann EH, Messer HH, Adams GG: The relationship of intra-
20(3):127, 1994. canal medicaments to postoperative pain in endodontics, Int Endod
186. Walton RE, Holton IFJ, Michelich R: Calcium hydroxide as an J 36(12):868, 2003.
intracanal medication: effect on posttreatment pain, J Endod 208. Chance K, Lin L, Shovlin FE, Skribner J: Clinical trial of intracanal
29(10):627, 2003. corticosteroid in root canal therapy, J Endod 13(9):466, 1987.
187. Rivera EM, Williams K: Placement of calcium hydroxide in 209. Chance KB, Lin L, Skribner JE: Corticosteroid use in acute apical
simulated canals: comparison of glycerin versus water, J Endod periodontitis: a review with clinical implications, Clin Prev Dent
20(9):445, 1994. 10(1):7, 1988.
188. Sigurdsson A, Stancill R, Madison S: Intracanal placement of 210. Dametto FR, Ferraz CCR, Paula B, et al.: In vitro assessment of the
Ca(OH)2: a comparison of techniques, J Endod 18(8):367, immediate and prolonged antimicrobial action of chlorhexidine gel
1992. as an endodontic irrigant against Enterococcus faecalis, Oral Surg
189. Torres CP, Apicella MJ, Yancich PP, Parker MH: Intracanal place- Oral Med Oral Pathol Oral Radiol Endod 99(6):768, 2005.
ment of calcium hydroxide: a comparison of techniques, revisited, 211. Dammaschke T, Schneider U, Stratmann U, et al.: Effect of root
J Endod 30(4):225, 2004. canal dressings on the regeneration of inflamed periapical tissue,
190. Lambrianidis T, Kosti E, Boutsioukis C, Mazinis M: Removal Acta Odont Scand 63(3):143, 2005.
efficacy of various calcium hydroxide/chlorhexidine medicaments 212. Gomes BPFD, Vianna ME, Sena NT, et al.: In vitro evaluation
from the root canal, Int Endod J 39(1):55, 2006. of the antimicrobial activity of calcium hydroxide combined with
191. Chang YC, Tai KW, Chou LS, Chou MY: Effects of camphorated chlorhexidine gel used as intracanal medicament, Oral Surg Oral
parachlorophenol on human periodontal ligament cells in vitro, J Med Oral Pathol Oral Radiol Endod 102(4):544, 2006.
Endod 25(12):779, 1999. 213. De Rossi A, Silva LAB, Leonardo MR, et al.: Effect of rotary or
192. Spångberg L: Cellular reaction to intracanal medicaments, Trans manual instrumentation, with or without a calcium hydroxide/1%
Int Conf Endod 5(0):108, 1973. chlorhexidine intracanal dressing, on the healing of experimentally
193. Spångberg L, Rutberg M, Rydinge E: Biologic effects of endodontic induced chronic periapical lesions, Oral Surg Oral Med Oral Pathol
antimicrobial agents, J Endod 5(6):166, 1979. Oral Radiol Endod 99(5):628, 2005.
Video 14.1: Removal of Smear Layer
Video 14.2: Cleaning and Shaping NiTi
Video 14.3: Cleaning and Shaping Combined
Video 14.4: Temporalization
326.e1
15
Obturation and
Temporization
NATASHA M. FLAKE AND JAMES D. JOHNSON
CHAPTER OUTLINE
Objectives of Obturation, 327 Obturation Techniques with Gutta-Percha, 334
When to Obturate, 327 Evaluation of Obturation, 341
Obturation Materials, 328 Temporization, 345
Sealers, 332
LEARNING OBJECTIVES
After reading this chapter, the student will be able to: 8. Identify types of sealers available on the market and describe
1. Explain the objectives of root canal obturation. their properties.
2. Explain the rationale for single-visit versus multi-visit 9. Explain how to perform different obturation techniques using
endodontic treatment and identify cases when each approach gutta-percha as an obturation material.
would be indicated. 10. Explain the advantages and disadvantages of different
3. Explain the rationale for smear layer removal. obturation techniques used with gutta-percha.
4. List the ideal properties of an obturation material. 11. Describe how obturation materials and techniques are
5. Identify obturation materials that have been used evaluated through research studies.
historically and explain why these materials are no longer 12. Describe how the results of obturation are clinically evaluated
used. and the impact of obturation on treatment outcomes.
6. Describe the properties, advantages, and disadvantages of 13. Explain the rationale for intraorifice barriers and identify
gutta-percha. materials used as barriers.
7. List the ideal properties of a root canal sealer. 14. Explain the importance of restoration following endodontic
treatment and list materials used for temporization.
Objectives of Obturation before obturation, healing is related to the quality of obturation.3

Although failure to obturate or poor obturation are not desir-
Success in endodontic therapy is dependent on adequate instrumen- able treatment options, these results demonstrate the important
tation, disinfection, and obturation of the root canal system. The concept that what is removed from the root canal system is more
objective of obturation is to create a watertight seal along the length important than how it is filled.
of the root canal system from the orifice to the apical termination.
Obturation prevents leakage of microorganisms and their byprod- When to Obturate
ucts into the root canal system from a coronal direction and leakage
of periapical tissue fluids into the root canal system from an apical One versus Two Visits
direction. This seal allows for prevention and healing of apical peri- The endodontic community has long debated the number of visits
odontitis (Question 15.1). After adequate obturation, an adequate in which root canal therapy should be completed. Should a tooth
coronal restoration is also necessary and significantly affects the be obturated during the same visit when it is instrumented? Factors
healing of apical periodontitis and the success of root canal therapy.1 influencing the answer to this question include the pulpal and periapi-
Interestingly, a periapical lesion may heal at least temporarily cal diagnoses, the radiographic presentation, the patient’s signs and
after root canal débridement without obturation.2 Research has symptoms, the degree of difficulty, patient management issues, and
shown that when bacteria are eliminated from the root canal sys- logistic concerns. In some cases, the degree of difficulty of the case
tem before obturation, healing of a periapical lesion occurs regard- dictates that the treatment be completed in more than one visit, for
less of the quality of obturation.3 However, if bacteria remain example, very calcified cases when additional time is needed to locate
327
328 C HA P T E R 1 5 Obturation and Temporization
and instrument canals. Patient management or medical issues may be removed before obturation. This is because the smear layer may
also dictate that treatment be completed in more than one visit, for contain microbes and their byproducts, which would remain in the
example, a patient who cannot recline for an extended period of time. canal if not removed, and because the smear layer may inhibit adhe-
Finally, logistic issues may dictate that treatment be completed in more sion of filling materials to the dentin walls and penetration into den-
than one visit, for example, a patient presents on an emergency basis, tinal tubules, thereby compromising the seal (Question 15.3). The
and the dentist has limited time in their schedule to treat the patient. smear layer is typically removed by irrigation with ethylenediamine-
Opinions vary regarding the advantages and disadvantages of tetraacetic acid, which serves as a chelating agent. Proprietary formula-
single- versus multiple-visit endodontic treatment when it comes tions may also be used (e.g., MTAD, SmearClear, QMix).9␣
to pulpal and periapical diagnoses, radiographic presentation, and
patient signs and symptoms. Consensus exists that a tooth with a
vital pulp may have root canal therapy completed in one visit (if
Obturation Materials
time permits), because the canals are not infected. Cases with a vital Ideal Properties of an Obturation Material
pulp include those with a pulpal diagnosis of symptomatic irrevers-
ible pulpitis, asymptomatic irreversible pulpitis, reversible pulpitis, Grossman suggested the ideal properties of an obturation
or a normal pulp. When root canal therapy is performed using material10 (Box 15.1). Currently, no material or combination of
proper infection control and disinfection protocols, completing materials satisfies all of these criteria.␣
treatment in one visit further precludes the possibility of recontami-
nation of the root canal system caused by coronal leakage between Core Obturating Materials
visits. Consensus also generally exists that root canal therapy should
not be completed in one visit when the patient has swelling associ- Core obturating materials are the primary materials used in obtu-
ated with an acute apical abscess, or when the canal cannot be dried ration and occupy the bulk of the space within the root canal
as a result of exudate draining from the periapical tissues. In these system. Core obturating materials are classified as either solid or
cases, the clinician should wait until the swelling has resolved and semisolid. Solid materials are introduced into the canal as a solid,
the canal can be dried completely before obturation. and they require a sealer to completely seal the canal. Semisolid
There is disagreement on whether teeth with a necrotic pulp and materials are introduced into the canal in a liquid, paste, or soft-
asymptomatic apical periodontitis, symptomatic apical periodontitis, or ened form, and then set up within the canal.
a chronic apical abscess should be treated with single- or multiple-visit
root canal therapy. The debate centers on the importance of disinfection Gutta-Percha
of the root canal system. The rationale for completing treatment in two Gutta-percha has been used as a root canal filling material for over
visits is that the intracanal medicament placed between visits facilitates 160 years.11,12 It is by far the most popular core obturation material
disinfection of the root canal system (Question 15.2). This approach is (Video 15.1).
supported by evidence from clinical studies looking at microbial sam-
pling of the root canal system. In a study investigating the role of infec- Composition
tion at the time of obturation in teeth that were treated in one visit, Commercial gutta-percha contains the following ingredients: zinc
teeth were sampled for bacteria before obturation, and all teeth were oxide 59% to 76%, gutta-percha 18% to 22%, waxes and resins
treated in one visit.4 After 5 years, complete healing occurred in 94% of 1% to 4%, and metal sulfates 1% to 18%.13 The gutta-percha is
cases with a negative culture and in 68% of cases with a positive culture the matrix, and the zinc oxide is the filler. The waxes and resins
before obturation. These results highlight the importance of completely are the plasticizers, and the metal sulfates, such as barium sulfate,
eliminating bacteria from the root canal system before obturation, provide the necessary radiopacity.
which may be aided by an intracanal medicament between visits. The stereochemical structure of gutta-percha is 1,4 trans poly-
Despite the microbiologic rationale for completing root canal isoprene, whereas the stereochemical structure of natural rubber
therapy of necrotic teeth in multiple visits using an intracanal medi- is 1,4 cis polyisoprene.14,15 Even though gutta-percha and natural
cament, the available outcomes studies do not support an improved rubber have similar stereochemical structures, studies have shown
prognosis with two-visit treatment. Multiple systematic reviews that there is no cross-reactivity of gutta-percha and natural rubber
have found no significant difference in radiologic success of root latex in individuals who have a latex allergy.16,17
canal therapy between single- and multiple-visit treatment.5,6 How-
ever, there is some evidence that patients having single-visit root
canal therapy may be more likely to experience pain or flare-up and BOX 15.1 Desirable Properties of Obturating
use analgesics in the short-term after treatment.5,6 Unfortunately, Materials
the overall quality of the evidence is poor, because many studies
have limitations including low power and risk of bias.5-7 Thus the Grossman suggested that the ideal obturation material would have the following
debate is ongoing, and the decision to treat in one visit or two is properties:
ultimately at the discretion of the clinician for each individual case.␣
Smear Layer Removal

The smear layer is a combination of organic and inorganic debris pres-
ent on the root canal walls after instrumentation. When viewed under
scanning electron microscope, the smear layer has an amorphous,
irregular appearance that represents dentinal shavings, tissue debris,
odontoblastic processes, and bacteria and their byproducts.8 Histori-
cally, whether or not to remove the smear layer has been debated;
though there is now generalized agreement that the smear layer should
CHAPTER 15 Obturation and Temporization 329
A B
Fig. 15.1 Gutta-percha cones are available in a variety of tip sizes and tapers. (A) International Organiza-
tion for Standardization size 30 tip size gutta-percha cones of tapers of 0.02, 0.04, and 0.06. (B) Nonstan-
dardized gutta-percha cones with feathered tips.
Gutta-percha has two crystalline forms, alpha and beta.14,18

Depending on the temperature, gutta-percha can be in different
crystalline forms and exhibit different physical characteristics.
Commercial gutta-percha comes in the beta crystalline form at
room temperature. When the beta form is heated to 42°C to 49°C,
it transitions into the alpha phase. When alpha phase gutta-percha
is heated above 53°C to 59°C, it transitions into the amorphous
phase. This is important when the clinician needs the amorphous
form of gutta-percha to flow into all parts of the root canal system
utilizing thermoplastic techniques.19-22␣
Shapes
Gutta-percha is formed into either standard or nonstandard cones
of different tip sizes and tapers (Fig. 15.1). Standardized cones
conform to the requirements of the International Organization
for Standardization (ISO) or the American Dental Association/
American National Standards Institute (ADA/ANSI). Nonstan-
dardized (conventional) gutta-percha cones do not conform to the
standards set by ISO or ADA/ANSI. Standardized gutta-percha
cones are manufactured to have the same tip size and taper as the
corresponding endodontic instruments used in the preparation of
the root canal system. The original specifications called for gutta-
percha to have a taper of .02 mm per millimeter increase in length.
With the advent of various tapers in endodontic files, gutta-percha
cones now come in various tapers, including .04, .06, and so on.
Nonstandardized gutta-percha cones end in a feathered tip. Gutta-
percha used with thermoplasticizing devices is manufactured as
Fig. 15.2 Gutta-percha for use in thermoplasticized injection systems
pellets or contained in cartridges (Fig. 15.2). The pellets or car-
is manufactured in cartridges and pellets that fit into their corresponding
tridges are inserted into a thermoplasticized gutta-percha injection injection systems.
system, and the gutta-percha is heated before dispensing.␣
Advantages
Gutta-percha is by far the most popular and widely accepted root
canal filling material. Although it does not meet all of the criteria for
an ideal filling material, it satisfies most of them. Gutta-percha has
a number of advantages. First, because of its plasticity, gutta-percha
adapts well when compacted into prepared root canals, especially
when thermoplasticized. Second, gutta-percha has good handling
characteristics and is easy to manipulate with multiple obturation
techniques. It is relatively stiff and easily placed into canals. Third,
gutta-percha is relatively easy to remove from the root canal system,
either to create post space or for retreatment. Fourth, gutta-percha A
is regarded as a very acceptable material with good biocompatibility
with the periapical tissues (Question 15.4).␣
Sealability
To produce an adequate seal, gutta-percha must be used with a
sealer.10 Gutta-percha does not adhere to canal walls, so the space
between the gutta-percha and the canal wall must be sealed with a
root canal sealer. Additionally, the application of heat or solvents
to gutta-percha during different obturation techniques can cause
gutta-percha to shrink, further increasing the space between the
canal wall and gutta-percha core.␣
Other Additives to Gutta-Percha

Other ingredients have been added to some brands of gutta-percha
to increase its antibacterial properties. Calcium hydroxide has been
added to gutta-percha points by Coltene/Whaledent (Langenau,
Germany). Activ Point (Coltene/Whaledent, Langenau, Germany)
contains chlorhexidine. Other gutta-percha has been introduced
that contains iodine-polyvinylpyrrolidone. Although these addi-
tives to gutta-percha have been shown to be effective against various
bacteria,23-27 long term clinical studies have not been conducted.␣
Carrier-Based Gutta-Percha
Several brands of carrier-based gutta-percha are on the market
(Fig. 15.3). Carrier-based obturators are composed of gutta-percha
surrounding a carrier that is heated and then placed into the canal. B
The handle of the carrier is cut off and removed, leaving the gutta-
percha and carrier in the canal. Many obturators are designed to fit Fig. 15.3 Most obturators consist of a carrier core surrounded by gutta-
corresponding file systems. Several carrier-based obturators are mar- percha. The obturator is warmed and inserted into the canal. (A) Gut-
taCore obturators. (Courtesy Dentsply Sirona.) (B) SimpliFill is a type of
keted by Dentsply Sirona (York, PA), including GuttaCore, Gut-
carrier-based obturator that is not heated. The metal carrier is twisted off,
taCore for WaveOne Gold, WaveOne Gold Obturators, ProTaper leaving only an apical plug of gutta-percha. SimpliFill is available in large
Next Obturators, ProTaper Universal Obturators, Thermafil Plus apical sizes. (Courtesy Kerr Endodontics.)
Obturators, Vortex Obturators, GT Obturators, and GT Series X
Obturators. Soft-Core is a similar carrier-based obturator marketed
by Kerr Endodontics (Orange, CA). SimpliFill (Kerr Endodontics) immature or open apices29 (Fig. 15.4). Attributes of MTA include
is a 5-mm apical plug of gutta-percha on the end of a metal car- biocompatibility, sealability, and a history of documented positive
rier. It has the advantage of not leaving the carrier in the canal, as clinical outcomes. Similar to MTA, some of the more recently
the carrier is twisted off and removed, leaving only the apical plug of introduced bioceramic materials can also be used as obturation
gutta-percha. SuccessFil is a carrier-based gutta-percha system that materials in this fashion. Teeth with open apices where obturation
is combined with the UltraFil thermoplasticizied injection system to with MTA or other bioceramic material would be indicated are
create what is marketed as the Trifecta System (Coltene/Whaledent, considered moderate or high level of difficulty cases, and referral
Langenau, Germany). JS Quick-Fill (JS Dental Manufacturing, Inc, to a specialist is typically recommended (Video 15.2).30,31␣
Ridgefield, CT) is an alpha phase gutta-percha coated titanium core
in ISO sizes 15 to 60. The carrier-based material is spun into the canal Silver Points
at low speed, and the core may be left in the canal or slowly removed.␣ Silver points were used historically in the mid-1900s and were
manufactured to match the size and taper of endodontic hand
Mineral Trioxide Aggregate files used in canal preparation at that time (Fig. 15.5). Thus sil-
Mineral trioxide aggregate (MTA) is a bioactive calcium silicate ver points had a 0.02 taper. Silver points fulfilled some of Gross-
material that has many clinical applications in endodontics, man’s requirements of an ideal obturation material. They were
including vital pulp therapy, perforation repairs, and root end easy to insert and had good length control. However, they did not
surgery.28,29 MTA is used as an obturation material in cases of seal well laterally or apically as a result of their lack of plasticity.
declined as a result of their disadvantages. Silver points are not

recommended for use in modern endodontic therapy.37 The char-
acteristic appearance of silver points make them easily identifiable
on patients’ periapical radiographs (Fig. 15.6). These teeth may
require retreatment if pathosis is present or post space is needed;
however, prophylactic retreatment of teeth obturated with silver
points is not indicated.37␣
Resin
Resin-based obturation materials were used in the early 2000s.
Resilon and RealSeal were composed of a polycaprolactone core
material with difunctional methacrylate resin, bioactive glass, bis-
muth and barium salts as fillers, and pigments. These products
were used with a resin sealer (Epiphany or RealSeal) that was pack-
aged with the core filling material. The rationale for the product
was to create a “monoblock,” consisting of a resin sealer with resin
tags that enter and bond to dentinal tubules on the canal wall, and
which also adhesively bonds to the core material. The product was
light cured and sealed coronally as well. The system consisted of a
primer, a sealer, and synthetic polymer points or pellets. Research
has shown no advantage of these materials over gutta-percha,38-44
and resin-based obturating materials are no longer on the market.␣
Fig. 15.4 Four-year follow-up radiograph of tooth #9 that was obturated
with MTA when the patient was 7 years old. The patient experienced Pastes (Semisolids)
trauma, and the tooth became necrotic before the apex had fully matured. Pastes are a type of semisolid material that have been used as a core
filling material. Zinc oxide is a major component of most paste
materials. Because of the solubility of zinc oxide, these pastes do
not make effective core filling materials. Other disadvantages of
pastes include difficult length control, shrinkage of the material,
voids in obturation, and toxic ingredients in some pastes.
One paste filling material is a resorcin-formaldehyde paste,
which is a type of phenol-formaldehyde or Bakelite resin.45,46
Because this material has been widely used in Eastern Euro-
pean countries, and because it stains teeth a characteristic dark
red color, it is commonly referred to as Russian Red (Fig. 15.7).
This material has the advantage of being very antimicrobial, but
has the disadvantage of shrinkage once placed in the canal. Addi-
tionally, retreatments can be very difficult if the resin sets com-
pletely and there is sufficient bulk to the material46 (Fig. 15.8).
Paraformaldehyde-based pastes are another type of paste fill.
The rationale for adding paraformaldehyde to pastes is to provide
antimicrobial and mummifying effects. However, paraformalde-
hyde has severe toxicity to host tissues, and this negates the benefit
of any antimicrobial effects it may possess in endodontic materi-
als. These pastes are known as N2 (Indrag-Agsa, Losone, Switzer-
land), Sargenti, or RC2B, and are made of a liquid and powder.
The powder contains zinc oxide, bismuth nitrate, bismuth carbon-
ate, paraformaldehyde, and titanium oxide. The liquid consists of
eugenol, peanut oil, and rose oil.47 N2 has changed in response
to studies identifying toxic substances, such as lead oxide, and
Fig. 15.5 Silver points had a 0.02 taper and were manufactured in a vari- organic mercury.48 However, it still contains 4% to 8% parafor-
ety of tip sizes to match endodontic hand files. maldehyde.49 N2 is extremely toxic,50,51 and because it is used as a
paste, the extrusion of this material has caused permanent damage
Silver points did not adequately fill all of the canal space and in many cases. The material affects bone and soft tissue and can
could not be compacted into voids within the root canal sys- cause permanent neurologic damage resulting in paresthesia, dys-
tem. The shape of silver points remained round after insertion, esthesia, and pain. Because of the toxicity, risks to patients, legal
and canals are rarely prepared to a perfectly round shape. The issues, and the fact that there are numerous other acceptable obtu-
remaining space was filled with sealer, leading to leakage. This rating materials available that provide a better outcome, the use
leakage allowed for corrosion of the silver points and the forma- of these materials in modern day endodontics is not acceptable.
tion of silver salts, which were found to be cytotoxic.32-36 With The Food and Drug Administration lists N2 as an unapproved
modern techniques, instrumentation and obturation of smaller drug that is not legally imported or shipped across interstate lines,
canals with gutta-percha is predictable, so the use of silver points and the ADA does not approve of its use.52,53 In summary, use
Fig. 15.6 The mandibular left first molar was initially obturated with silver points, and the tooth was
retreated decades later when the patient presented with symptomatic apical periodontitis. Note the char-
acteristic appearance of the silver points in the mesiobuccal and mesiolingual canals of the preoperative
radiograph on the left. The postoperative radiograph on the right is the tooth after retreatment and filling
with gutta-percha. (Courtesy Dr. Patrick Mullally.)
of paraformaldehyde-containing endodontic filling materials and Rickert’s was one of the first zinc oxide sealers. The powder
sealers is below standard of care, as they have been shown to be contains zinc oxide, silver, resins, and thymol iodide. The liquid
both unsafe and ineffective.54␣ is eugenol, and Canada balsam. One disadvantage is that the sil-
ver used to provide radiopacity can also cause staining of tooth
Sealers structure. Another disadvantage is its rapid setting time in areas of
high humidity and heat. Rickert’s sealer is marketed as Kerr Pulp
Sealer is used in conjunction with a core obturating material and is Canal Sealer (Kerr Endodontics, Orange, CA), which has tradi-
necessary to fulfill the objective of creating a watertight seal in the tionally been popular with clinicians who use the warm vertical
root canal system (Question 15.5). In addition to the basic require- obturation technique. Pulp Canal Sealer Extended Working Time
ments for core filling materials, Grossman also identified the ideal (EWT) (Kerr Endodontics, Orange, CA), with a working time
requirements for a root canal sealer (Box 15.2).10 As with core obtu- of 6 hours, was introduced to lengthen the setting time over Kerr
ration materials, no sealer currently satisfies all of these criteria. Pulp Canal Sealer.62
Additionally, the following two requirements could be added Tubli-Seal (Kerr Endodontics, Orange, CA) was developed
to Grossman’s original basic requirements: it should not provoke as a nonstaining alternative to the silver containing Pulp Canal
an immune response in periradicular tissues,55-58 and it should be Sealer. Tubli-Seal comes as two separate tubes. One tube contains
neither mutagenic nor carcinogenic. 59,60 a zinc oxide-base paste with barium sulfate for radiopacity, min-
eral oil, cornstarch, and lecithin. The catalyst tube contains poly-
pale resin, eugenol, and thymol iodide. Tubli-Seal is easy to mix
Types of Sealers and has a short setting time.62 Tubli-Seal EWT was developed to
The primary sealers in use today are those based on zinc oxide provide extended working time.
eugenol (ZOE), resin, calcium hydroxide, or bioceramics. Wach’s cement is made up of a powder of zinc oxide, bismuth
subnitrate, bismuth subiodide, magnesium oxide, and calcium
Zinc Oxide Eugenol Sealers phosphate. The liquid consists of oil of cloves, eucalyptol, Canada
Zinc oxide eugenol (ZOE)-containing sealers have been widely balsam, and beechwood creosote. Wach’s cement has a distinc-
used with success for many years. There are many formulations tive odor of an old-time dental office.62 It has a smooth consis-
and brands of sealers with zinc oxide as the primary ingredient, tency, and the Canada balsam makes the sealer tacky. Medicated
differing only by other added components. ZOE sealers allow Canal Sealer (Medidenta, Woodside, NY) contains iodoform for
for the addition of chemicals, such as paraformaldehyde, rosin, antibacterial purposes and is to be used with MGP gutta-percha,
Canada balsam, and others, all of which may increase the toxicity which also contains 10% iodoform.63␣
of that particular sealer.49 Grossman’s original formula contained
zinc oxide, hydrogenated or Staybelite resin, bismuth subcarbon- Calcium Hydroxide Sealers
ate, barium sulfate, and sodium borate (anhydrous), with euge- Sealapex (Kerr Endodontics, Orange, CA) is a noneugenol poly-
nol as the liquid component.61 It has been marketed as Proco-sol meric sealer that contains calcium hydroxide. It is packaged in
sealer (StarDental, Lancaster, PA), as well as other product names. two tubes, one of which is a base, and the other a catalyst. Sea-
Roth’s 801 and 811 sealers (Roth’s International LTD, Chicago, lapex has zinc oxide in the base plus calcium hydroxide. It also
IL) were essentially the same as Grossman’s original formulation, contains butyl benzene, sulfonamide, and zinc stearate. The cata-
with the substitution of bismuth subnitrate for bismuth subcar- lyst tube has barium sulfate and titanium dioxide for radiopac-
bonate. Despite its popularity, production of Roth’s sealer recently ity, and a proprietary resin, isobutyl salicylate, and AEROSIL
ceased. R792.62 Sealapex has similar sealing ability as Tubli-Seal.64 Apexit
York, PA). AH26 is a sealer that has been used for many years.
It is a bisphenol epoxy resin sealer that uses hexamethylenetetra-
mine (methenamine) for polymerization.45,65 A major disadvan-
tage of AH26 was that the methenamine gave off formaldehyde
as it set. It would also stain tooth structure and had an extended
working time. One advantage of AH26 is it was not affected
by moisture.62 AH Plus and ThermaSeal Plus (Dentsply Sirona,
York, PA) are formulated with a mixture of amines that allows
for polymerization without the unwanted formation of formal-
dehyde.65,66 They have the advantages of AH26, which include
increased radiopacity, low solubility, slight amount of shrinkage,
and tissue computability. AH Plus is an bisphenol epoxy resin
that also contains adamantine.45 AH Plus comes in a two paste
system, unlike the liquid-powder system of AH26, and has a
working time of 4 hours and a setting time of 8 hours. Addi-
tional improvements of AH Plus over AH26 include thinner
A film thickness and decreased solubility.␣
Bioceramic Sealers
Mineral trioxide aggregate (MTA) is a calcium silicate bioceramic
material, which has many applications in endodontics. MTA has
been a very successful material because of its biologic and physical
characteristics. MTA is extremely biocompatible and provides a
good seal. Because of these biologic and physical attributes, several
bioceramic sealers are now on the market. ProRoot Endo Sealer
(Dentsply Sirona, York, PA) is an MTA-based sealer manufactured
in a powder and gel form. The powder is MTA with enhanced
radiopacity, which contains tricalcium silicate, dicalcium silicate,
calcium sulfate, bismuth oxide, and a small amount of trical-
cium aluminate. The gel is a viscous aqueous solution of a water
soluble polymer. MTAFillapex (Angelus, Londrina, PR, Brazil)
is a dual paste system. It contains salicylate resin, diluent resin,
natural resin, bismuth oxide, nanoparticulate silica, MTA, and
pigments. Endosequence BC Sealer (Root SP) (Brasseler USA,
Savannah, GA) is a calcium silicate based sealer manufactured as a
single paste system. It contains zirconium oxide, calcium silicates,
calcium phosphate monobasic (CaH2P2O8), calcium hydroxide,
filler, and thickening agents. iRoot SP (Innovative BioCeramix
Inc., Vancouver, Canada) is another calcium silicate based sealer
that contains zirconium oxide, calcium silicates, calcium phos-
phate, calcium hydroxide, filler, and thickening agents.␣
B Silicone Based Sealers

Silicone based sealers provide adhesion, a moisture resistant seal,
Fig. 15.7 This mandibular molar was treated with a resorcinol-formalde- and stability.45 Lee Endo-Fill (Lee Pharmaceuticals, El Monte,
hyde resin paste. Dark red-stained dentin can be seen both through the
CA) is a silicone based root canal sealer. RoekoSeal (Coltene/
occlusal surface and upon access. The dentin is solid.
Whaledent, Langenau, Germany) is a polyvinylsiloxane that is
a white paste-like sealer and will polymerize without shrinkage,
(Ivoclar Vivadent, Schaan, Liechtenstein) is a calcium hydroxide which results in less leakage.45,67 It utilizes platinum as a cata-
sealer with salicylates also incorporated into the formula. CRCS lyzing agent.45 GuttaFlow (Coltene/Whaledent, Langenau, Ger-
(Calciobiotic Root Canal Sealer, Coltene/Whaledent, Mahwah, many) is a polyvinylsiloxane that has finely milled gutta-percha
NJ) is a calcium hydroxide-containing sealer that has a zinc oxide- particles added to the RoekoSeal sealer. GuttaFlow additionally
eugenol and eucalyptol base. CRCS is a rather slow-setting sealer, contains silicone oil, paraffin oil, platin catalyst, zirconium diox-
especially in dry or in humid climates. It may require up to 3 days ide, nano-silver as a preservative, and a coloring agent. It does
to fully set.62 The set sealer is quite stable, which improves its seal- not contain eugenol. GuttaFlow is a cold flowable gutta-percha
ing qualities, but may mean that calcium hydroxide is not as read- filling system for the obturation of root canals. GuttaFlow is
ily released and the stimulation of cementum and bone formation triturated in its cannula and passively injected into the canal and
may be severely limited.␣ then used with single or multiple gutta-percha points.␣
Resin Sealers Urethane Methacrylate Sealers
Epoxy resin sealers have been used in endodontics for some time, EndoREZ (Ultradent, South Jordon, UT) is a hydrophilic ure-
including AH26, and its successor AH Plus (Dentsply Sirona, thane dimethacrylate (UDMA) resin sealer that reportedly has
A B
Fig. 15.8 The maxillary right lateral and central incisor were treated with a resorcinol-formaldehyde resin
paste. (A) The teeth have characteristic voids visible radiographically in the obturation, especially tooth
#7, as seen in this preoperative radiograph. All of the paste could not be removed during nonsurgical
retreatment of tooth #8, so root-end surgery was performed. (B) Tooth #7 was later successfully retreated
nonsurgically, as shown in this postoperative radiograph.
BOX 15.2 Requirements for an Ideal Root Canal Evaluation and Comparison of Sealers
Sealing Material Orstavik45,68 has listed the various evaluation parameters for test-
ing endodontic sealers. They include technologic tests that have
been standardized by the ISO and ADA/ANSI internationally and
in the United States. These technological tests include flow, work-
ing time, setting time, radiopacity, solubility and disintegration,
and dimensional change after setting. Additionally, biologic tests,
usage testing, and antibacterial testing are useful. Clinical testing
should be included to establish outcomes of treatment.
Study Questions
9. It should be insoluble in tissue fluids.
good canal wetting and flow into dentinal tubules.67 The hydro-
philic property improves its sealing abilities if some moisture is
still in the canal at obturation.45 EndoREZ is introduced into Obturation Techniques with Gutta-Percha
the canal with a narrow 30-gauge NaviTip needle (Ultradent). A
single gutta-percha point, or the lateral compaction obturation Gutta-percha is the most widely used and clinically acceptable obtu-
technique, may be utilized. EZ Fill (Essential Dental Systems, ration material, thus the techniques described in this chapter will
South Hackensack, NJ) is a noneugenol epoxy resin sealer that focus on the use of this material. Gutta-percha is available in many
is placed with a bidirectional spiral rotating in a hand piece. It different forms and sizes, both gutta-percha cones and gutta-percha
may be used with a single gutta-percha point technique. It is non- for thermoplasticized injection systems (see Figs. 15.1 and 15.2). The
shrinking on setting and is hydrophobic, rendering it resistant to choice of obturation method is primarily based on clinician training
fluid degradation.␣ and preference, as well as the specific anatomy of each case. There are
Master
gutta-percha
point
Fig. 15.9 The master cone should have slight frictional fit in the most api-
cal portion of the canal.
attributes and limitations of each technique, but no significant dif- A

ference in outcomes has been demonstrated between contemporary
obturation techniques using gutta-percha (Video 15.1).69,70
Cold Lateral Condensation

Cold lateral condensation (commonly referred to as lateral conden-
sation or lateral compaction) is the most common obturation tech-
nique taught to predoctoral dental students.71 Advantages of lateral
condensation are that it can be used in a wide variety of cases, does
not require specialized equipment, and has a track record of clini-
cal success. In addition, lateral condensation is safe and simple to
learn for novice clinicians; it is less technique-sensitive than other
methods and has predictable length control (less likely to overfill).
A disadvantage of lateral condensation is that it requires more time
than some filling techniques.72 In addition, it is challenging to use
in some clinical cases (e.g., very curved canals, internal resorption,
wide open apices, or other anomalous canal anatomy) (Question B
15.6). However, these cases are considered “high difficulty” and are
typically referred to a specialist for treatment.30,31 Fig. 15.10 (A) A master cone that buckles near the tip when inserted into
The technique for lateral condensation, and all obturation the canal is too small. (B) A larger cone should be selected or clipped to
techniques, varies slightly from clinician to clinician. The follow- form a larger size at the tip.
ing is a description of a traditional lateral condensation technique.
1. The canal is dried. A paper point placed to working length near the tip may be too small (Fig. 15.10). A cone that buckles
should come out of the canal dry, with no irrigant, blood, or more coronally may be too large (it will appear that the cone
exudate on it. is seating to working length because the cotton pliers seat to
2. A master gutta-percha cone is selected. Gutta-percha cones the reference point, but the cone will be short as a result of the
should be handled using cotton pliers (locking are preferred), buckling). Variations of selecting a master cone preferred by
and measured using a millimeter ruler. In classic cold lateral some clinicians include using a 0.04 taper cone or a nonstan-
condensation, the master cone is a 0.02 taper cone and has dardized cone with the tip cut to a custom diameter. Special-
a tip size that matches the master apical file size to which ized instruments are available on the market to help cut the
the canal has been prepared. The selected cone should seat tip of gutta-percha cones to a specific diameter (Fig. 15.11).
to working length, not be able to be pushed beyond work- Often the clinician may try multiple master cones, even of the
ing length, and exhibit a sensation of slight resistance when same size, before selecting the master cone they want to use
removing the cone from the canal. This resistance (referred for obturation of a canal. As a result of manufacturing varia-
to as tug-back) indicates that the cone is binding the walls of tions, there will be variations in gutta-percha cone actual sizes,
the canal (Fig. 15.9). A master cone that does not seat all the even among those labeled as the same ISO size and taper.73
way to working length is too large (i.e., it is binding short of 3. Sealer is placed in the canal. Different methods have been
working length). A master cone that can be pushed beyond used to apply sealer to the walls of the canal. These include
working length is too small (i.e., it is not binding at working using a hand file place to length and spinning counterclock-
length and overfilling will result). A master cone that does not wise, using a lentulo spiral drill, and using the master cone
display any resistance upon removal is also too small (i.e., it (Fig. 15.12). The goal is to have a thin layer of sealer on all
is not snug at working length), though this sensation can be walls of the canal. In most cases, sealer is placed both in the
difficult to detect. Careful inspection should catch any cone canal before seating the master cone, and on the master cone
that buckles when placed to working length and removed; this itself before seating it. The choice of sealer type is up to the
indicates that the cone does not fit well. A cone that buckles discretion of the clinician.
Fig. 15.13 Size 30 finger spreader. (Courtesy Dentsply Sirona.)
4. Sealer is placed on the master cone, and the master cone is

seated in the canal to working length. The cone is seated
using gentle, continuous pressure. If the cone does not seat
to length on the first attempt, it should be pulled out a few
millimeters and slowly reseated. The master cone may need to
be gently “pumped” up and down a few times to get the cone
to seat to the desired working length.
5. A spreader is selected for use in lateral condensation. The
length, size, and degree of taper varies between spread-
ers. Nickel-titanium finger spreaders or stainless steel hand
spreaders may be used (Fig. 15.13). Nickel-titanium finger
spreaders have the advantages of being able to be inserted
into the canal to a greater depth while exerting less force on
the canal walls74-76 (Fig. 15.14). Finger spreaders also are
preferred by many because they are gripped and used in a
fashion similar to finger files, and they may be easier to access
difficult areas of the mouth. The chosen spreader should be
able to be placed in the canal to within approximately 1 to 2
mm of the working length.
6. The spreader is placed into the canal and rotated using a back-
and-forth motion, keeping the long axis of the spreader in the
B same plane, to create lateral space within the canal. Moderate
pressure is applied in an apical direction, while rotating the
Fig. 15.11 Specialized instruments for cutting gutta-percha cones to handle through an arc of approximately 30 degrees. The api-
a customized International Organization for Standardization tip size are
cal force is kept on the long axis of the spreader. The spreader
commercially available. (A) Gutta Gauge. (Courtesy Dentsply Sirona.) (B)
Tip Snip. (Courtesy Kerr Endodontics.)
will feel looser as it is moved in this motion. The spreader is
removed from the canal also using a back-and-forth motion.
During removal of the spreader, it is recommended to hold
the tip of the cone(s) that have already been seated in the
canal, to prevent the master cone and any accessory cones
from being dislodged from working length.
7. Accessory cones are added in the space created by the spreader
(Fig. 15.15). Different types of accessory cones may be used,
and the cones are matched to the spreader size. Commonly,
nonstandardized cones or size 25, 0.02 taper standardized
cones are used as accessory cones. In very large canals, larger
accessory cones and a larger size spreader may be used. Cau-
tion must be exercised during lateral condensation not to use
too much force in the canal during the condensation process
(this same caution should be used during other techniques as
well). It is recommended that the force used should be no more
than 2.5 lbs, in order to avoid vertical root fracture77,78 (Fig.
15.16).
8. Most clinicians choose to expose a radiograph after the mas-
ter cone is seated in the canal. The purpose for the “master
Fig. 15.12 A simple, effective method of sealer application. A hand file cone radiograph” is to check that the gutta-percha is seated
covered with sealer is inserted into the canal and spun counterclockwise to the desired working length (not short and not long).
to coat the canal walls. Alternatively, the clinician may choose to add one to two
A B
Fig. 15.14 Comparison of hand spreader with finger spreader. (A) The stiff, more tapered hand spreader
will not negotiate the curve. (B) The smaller, more flexible finger spreader permits deeper penetration and
produces less force on the canal wall.
A B C D
Fig. 15.15 The steps of lateral condensation. (A) The master cone is fit. (B) A spreader is inserted, ideally
to 1 to 2 mm from working length. (C) The spreader is rotated and removed, and an accessory cone is
placed in the space created. (D) The process is repeated.
accessory cones before exposing the radiograph. This “initial 10. When the appropriate level of obturation is reached, the
condensation radiograph” is used to check the length of the gutta-percha cones are seared off at the desired level. An
gutta-percha, that the master cone is not dislodged during electrically heated plugger can be used to sear off the cones
the initial condensation, and that no voids are present in the (Fig. 15.19). Historically, a Bunsen burner or alcohol torch
apical third of the canal. If an error is detected on the master with a hand plugger were used and may be used if an elec-
cone or initial condensation radiograph, it is still possible to trically heater plugger is not available. A cold hand plugger
easily remove the cone(s) from the canal, before they have is used to plug the remaining gutta-percha vertically, filling
been seared off, and correct the error or chose a new master any coronal voids and creating a smooth surface of gutta-
cone. Cones are removed by slowly pulling the gutta-percha percha in the coronal aspect of the canal (Fig. 15.20). If
from the canal. an intraorifice barrier is to be placed, the desired level of
9. If the master cone or initial condensation radiograph is gutta-percha is 1 to 2 mm apical to the level of the facial
acceptable, then lateral condensation continues (Fig. 15.17). cemento-enamel junction (CEJ) or the pulp chamber floor
The spreader is used, and subsequent accessory cones are (in a molar). The 1 to 2 mm space is then filled with the
also coated in sealer before placement in the canal. As more intraorifice barrier material. If an intraorifice barrier is not
accessory cones are added, the spreader will seat less and less placed, then the gutta-percha is brought to the level of
deep in the canal. Condensation should continue until the the facial CEJ or the pulp chamber floor. If post space is
spreader can no longer be placed more than approximately needed, additional gutta-percha may be removed to a level
4 mm below the level of the orifice (Fig. 15.18). as appropriate for the post space.␣
A B
C
Fig. 15.16 Excessive force used during lateral condensation, or any obturation technique, can lead to
vertical root fracture. (A) Periapical radiograph of tooth #4 with a vertical root fracture. (B) The vertical root
fracture is visualized extending up the buccal surface from an apical direction. The root has been stained
with methylene blue for better visualization. (C) The fracture extends into the buccal canal, as seen from
the apical direction. (Courtesy Dr. Alex Hanley.)
Warm Vertical Condensation taper master cone is chosen). The cone should seat short of the
desired working length, up to 2 mm short. The warm vertical con-
Warm vertical condensation (also known as warm vertical compac- densation technique is expected to push the gutta-percha apically
tion or the Schilder technique) is another widely used obturation to the desired working length during condensation. Some clini-
method. The technique is commonly credited to Dr. Herb Schil- cians opt to select a master cone that seats snugly at working length.
der,79,80 although modifications have been made to the original tech- 2. Sealer is applied and the master cone is seated.
nique over the years as technology has advanced. The main advantage 3. The coronal portion of the cone is seared off at the orifice level
of warm vertical condensation is that warmed gutta-percha can be using an electrically heated plugger.
adapted to the canal walls, which is particularly desirable in irregularly 4. The remaining gutta-percha is plugged apically in the canal,
shaped canals, such as cases of internal resorption. Disadvantages of using a prefit cold hand plugger. The plugger should not bind
warm vertical condensation compared with lateral condensation are the sides of the canal during condensation. If the plugger is too
that it is more technique-sensitive, and length control is particularly large, it will bind the walls of the canal, creating excess force
difficult (higher risk of overfilling).70,81 Warm vertical condensation on the walls and risking vertical root fracture. If the plugger is
also requires additional instruments and equipment, and it is diffi- too small, it will poke indentations in the mass of gutta-percha,
cult to visualize the level of gutta-percha in the canal unless a dental rather than compacting it in an apical direction. The plugger is
operating microscope is used during treatment (Question 15.7). used to circumferentially plug the gutta-percha in the canal.
As with lateral condensation, the technique used for warm 5. The gutta-percha mass is seared off again, at a deeper level in
vertical condensation varies slightly from clinician to clinician. A the canal, and a “bite” of gutta-percha is removed from the
basic tenet for warm vertical condensation is that the preparation canal by inserting the heat source a few millimeters into the
should be a continuously tapering funnel with the apical foramen gutta-percha. The gutta-percha mass is plugged apically again
kept as small as possible. A description of a basic warm vertical using a cold hand plugger.
condensation follows, starting with a dried canal. 6. This process is repeated until the apical portion of the canal is
1. A master gutta-percha cone is selected. The cone usually replicates filled with an “apical plug” to a level 4 to 6 mm from work-
the canal taper (e.g., if a canal is prepared to a 0.04 taper, a 0.04 ing length. As the gutta-percha is plugged apically, the mass of
in one motion over 1 to 2 seconds, until the desired level of the

down pack is achieved. The heat plugger is inactivated, and pres-
sure is applied apically for 5 to 10 seconds, to reduce shrinkage
of the cooling gutta-percha. A burst of heat is then applied, as
A B C the plugger is moved side-to-side, to separate the plugger from
the apical gutta-percha. The plugger is then removed from the
canal, and any excess gutta-percha coronal to the down pack
level should be removed from the canal on the plugger. The api-
cal portion of gutta-percha is plugged apically with a cold plug-
ger, and the canal is backfilled, as in warm vertical condensation.
D E F The advantage of the continuous wave technique is the reduced
amount of time needed to obturate.72 A disadvantage is that
the method is quite technique-sensitive: the down pack of api-
cal gutta-percha may be removed with the plugger, or the coro-
nal gutta-percha may not be removed with the plugger. As with
G H I warm vertical compaction, length control is more difficult with
A. Prepared canal the continuous wave technique versus cold lateral condensation.␣
B. Master cone inserted
C. Spreader placed
D. Placement of accessory cone (shown as dashed circle) Formed Cones
E-H. Continuation of lateral compaction
I. Completion of obturation The use of a custom formed master cone is a variation used in
obturation. Formed cones are most commonly employed in con-
Fig. 15.17 Schematic of the steps of lateral condensation. Each insertion
junction with cold lateral condensation but may also be used
of the spreader to its most apical extent laterally compacts the gutta-per-
cha cone toward the opposing wall. At the completion of obturation, the
with warm vertical techniques. The technique involves selecting a
canal is filled with a series of cones that have been cold-welded together gutta-percha cone that is larger than the apical preparation of the
with sealer. (Courtesy Dr. J. Schweitzer.) canal, then softening the tip of the cone in chloroform so that an
“impression” of the apical few millimeters of the prepared canal
is created. Chloroform softens the outer skin of the gutta-percha.
gutta-percha is pushed to working length and into any canal The cone is then reseated after sealer has been placed in the canal.
irregularities. Note that caution must be exercised when using Some clinicians choose to use the formed cone technique on
an electrically heated plugger in the canal to avoid transmitting every case. Others employ it only in specific cases. Cases where the
dangerous levels of heat to the periodontal ligament.82,83 formed cone would be indicated include those with a large apical
7. The remainder of the canal is then backfilled with thermoplas- foramen, an irregularly shaped apical preparation, lack of an apical
ticized gutta-percha from an injection system (Fig. 15.21). The stop, or as a trouble-shooting technique when the master cone is not
warm injection tip is first placed in contact with the apical plug seating to working length (Question 15.8). The formed cone should
of gutta-percha, to warm the existing gutta-percha before more fit like a key in a lock when root canal sealer is applied and the cone
is added to the canal. Thermoplasticized gutta-percha is then is placed back into the canal in the same orientation in which it
injected, as the instrument is “backed out” of the canal. The was removed after making the impression. As condensation con-
injected gutta-percha is plugged apically with a cold plugger, tinues, the use of a spreader and/or plugger will cause the softened
with apical pressure being applied as the gutta-percha cools, gutta-percha to move into irregularities in the root canal system.
to minimize shrinkage. The backfill may be accomplished in The disadvantages of any gutta-percha solvent technique are the
one or more segments, depending on the length of the canal. time needed to form the cone and the potential for shrinkage of the
Before thermoplasticized gutta-percha injection systems were gutta-percha as the chloroform evaporates. In vitro testing suggests
commercially available, small segments of gutta-percha were the possibility of shrinkage after use of chloroform, but no clinical
added back to the canal, heated, and condensed. studies have shown shrinkage to be a clinically significant problem.
8. The backfilled gutta-percha is seared off at the desired level, as The formed cone technique is as follows:
with lateral condensation. The backfill may be stopped short, 1. An oversized gutta-percha master cone (that does not seat to
or not completed at all, if post space is desired.␣ working length) is selected. This is most commonly a 0.02
taper cone but could be a larger taper cone depending on the
Continuous Wave case and clinician preference. The cone should seat approxi-
mately 1 mm short of working length when placed in the canal
The continuous wave of condensation is a variation of warm with gentle pressure. This is typically a cone that is one to two
vertical compaction.84 Continuous wave primarily differs from sizes larger than the master apical file size.
warm vertical in the down pack procedure (down pack may refer 2. The cone is grasped with a locking cotton plier at the appropri-
to both the procedure for removing coronal gutta-percha from ate working length. The apical 3 to 4 mm of the cone is quickly
the canal, and the apical plug of gutta-percha that results). Clas- dipped into chloroform (for approximately 1 second). Other
sic warm vertical obturation accomplishes the down pack in solvents may also be used.
multiple steps of heating, removing gutta-percha, and plugging 3. The cone is seated with gentle but continuous pressure. The
vertically. In contrast, the continuous wave technique employs cone is pulled out a few millimeters and gently reseated in the
one continuous motion for the down pack. Once the master canal to mold or adapt the apical portion. The cone should seat
cone is seated, a prefit plugger is chosen. Electrically heated plug- to working length.
ger tips that match the taper of the canal are used (Fig. 15.22). 4. Measure to confirm that the cone seats to working length. If the
The warmed plugger is moved apically through the gutta-percha cone is short of working length, the cone may be dipped again in
A B C
D E F
G H
Fig. 15.18 Lateral condensation. (A) A hand file matching the size of the master apical file is inserted to ensure it seats to working length. (B) Standard-
ized gutta-percha cones are seated to working length. (C) The position of the cones is verified radiographically. (D) Once the sealer has been placed and
the cone seated to length, the spreader is inserted along the side of the cemented cone (here, in the mesiobuccal canal). (E) An accessory cone is placed
in the space created by the spreader. (F) The process is repeated (i.e., reinsertion of the spreader, followed by placement of another accessory cone)
until the spreader does not penetrate beyond the middle third of the canal. The cones are removed at the orifice with heat, and the coronal mass then is
vertically compacted. (G) The remaining canals are obturated in the same manner. (H) The final radiograph demonstrates four canals properly obturated.
(Courtesy Dr. W. Johnson.)
master apical file size, and some endodontic rotary files are mar-
keted with corresponding carriers as a “system.”
When the canal is ready to obturate, it is dried and sealer is
applied. The obturator is heated using a time- and temperature-con-
trolled oven, which softens the gutta-percha surrounding the carrier
(Fig. 15.24). The obturator is inserted into the canal to the appro-
priate working length. The carrier portion of the obturator is rigid
enough to carry the gutta-percha to working length but flexible
enough to be placed around common canal curvatures. The handle
of the carrier must then be removed, typically using a long-shank
round bur, and the coronal gutta-percha is smoothed using a plugger.
The advantages of carrier-based obturation are time efficiency
and the ability of warmed gutta-percha to fill canal irregulari-
ties.85 Disadvantages include length control (overfilling is a risk),
Fig. 15.19 An electrically heated plugger can be used to sear off gutta- and stripping of the gutta-percha off the carrier during seating.86
percha during obturation with lateral condensation, as well as carry heat As such, carrier-based obturation can be technique-sensitive. In
into the canal to remove gutta-percha during warm obturation techniques.
addition, post space preparation and retreatment are difficult, as
The Touch ‘n Heat was the first mass marketed electrically heated plugger,
and is still on the market today. (Courtesy Kerr Endodontics.)
retrieving the carrier from the canal may be challenging or impos-
sible in some cases (Question 15.9).
A variation on carrier-based obturation uses a metal carrier
with an apical plug of gutta-percha attached (see Fig. 15.3, B).
After the gutta-percha is seated to working length, the metal car-
rier is twisted off and removed from the canal, leaving an apical
plug of gutta-percha. This type of carrier is not heated.␣
Single Cone Obturation

Growing attention has been given in recent years to the use of a
“single-cone” obturation technique. In this technique, the canal is
obturated with a single gutta-percha cone that is designed to match
the size and taper of the canal preparation. For example, a canal
prepared to a master apical file of size 40/.04 would be obturated
with a single gutta-percha master cone of size 40/.04. Some clini-
cians advocate using a master cone one size smaller than the master
apical file size. The advantages of this technique are time efficiency
and length control. The main disadvantage is that the gutta-percha
Fig. 15.20 The gutta-percha has been seared off and vertically com-
pacted with a cold hand plugger at the level of the orifice in this maxillary
does not adapt to an irregularly shaped canal and voids may be
premolar. (Courtesy Dr. Kyle Countryman.) present along the length of the canal. The sealer is expected to fill
any irregularities in the canal. The technique has been popularized
in recent years in conjunction with the use of a bioceramic sealer.
chloroform and reseated using gentle continuous pressure, or a Despite the growing popularity of the single-cone technique, there
new cone may be used. If the cone buckles, it should be discarded. is little clinical research published evaluating its use.87␣
5. The tip of the cone is examined to make certain that the cone
has adapted to the apical canal (Fig. 15.23). If the cone has Evaluation of Obturation
properly formed, “skid marks” will be visible where the soft-
ened cone has touched the canal wall. Smooth, uninterrupted How Obturation Materials and Techniques Are
areas that look like the fresh cone are an indication that the Evaluated in Research
cone is too small and is not contacting the canal in all dimen-
sions. If this occurs, a new, larger cone should be formed, or the Obturation materials and techniques are commonly evaluated
tip of the softened cone should be trimmed and reformed. in research using in vitro studies.88 The quality or density of fill
6. After the master cone is formed, sealer is applied, and obtura- created by different obturation methods can be compared by fill-
tion is completed using the preferred technique.␣ ing extracted or artificial teeth using different methods. The teeth
are then sectioned at different levels of the root, and the cross-
sectional areas filled by gutta-percha, sealer, or voids are mea-
Carrier-Based Obturation sured.72,81 Microcomputed tomography imaging may be used
Carrier-based obturation utilizes an “obturator” composed of a in similar studies, where three-dimensional volumetric measure-
core carrier material surrounded by a gutta-percha coating that is ments can be made both before and after obturation of the root
used to fill the root canal system. The earliest version of an obtu- canal system; the volume of filled space can then be measured.89
rator had a metal core, but later versions have utilized plastic as Benchtop studies may also be used to investigate the fracture resis-
the core material. The most recently introduced core material is a tance of teeth or the presence of dentin microcracks after obtu-
crosslinked version of gutta-percha (see Fig. 15.3, A). Obturators ration with different methods or materials.90 In vitro studies are
are available in standardized sizes designed to match a designated also employed to assess the sealability of obturation techniques
A B
C D
Fig. 15.21 Thermoplasticized gutta-percha injection systems. (A) The Obtura system uses pellets of
gutta-percha, similar to a glue gun. (Courtesy Obtura Spartan.) (B) The Calamus Dual has both a heat
source and a gutta-percha injection hand piece on one console. The gutta-percha handpiece utilizes
cartridges of gutta-percha made to specifically fit in the handpiece. (Courtesy Dentsply Sirona.) (C and D)
The Elements Free and Gutta Smart systems are cordless, and each has both a heat source handpiece
and a gutta-percha injection handpiece with corresponding cartridges of gutta-percha made to fit each
product. Both cordless hand pieces share a charging base in each system. (Courtesy Kerr Endodontics
and Dentsply Sirona.)
or materials, where ability of bacteria to penetrate an obturated Radiographic evaluation of a previously treated tooth may provide
canal is measured.91 Further, biocompatibility and antimicrobial information about not only the quality of the previous treatment
effectiveness of obturation materials are also tested by in vitro cell (e.g., presence of voids) but the type of filling material used (e.g.,
culture and microbiologic research assays.92-94␣ silver points have a different radiographic appearance compared
with gutta-percha) (see Fig. 15.6). Cone beam computed tomog-
How Obturation Is Evaluated Clinically— raphy (CBCT) is not usually a helpful method to evaluate voids
in obturation, as a result of the scatter produced by the obturation
Radiographic Evaluation materials. However, the obturation observed on a CBCT image
In clinical cases, obturation is commonly evaluated using periapi- may show important information, such as when a canal has been
cal radiographs. The length, taper, and density of obturation are missed or transported (Fig. 15.25).
assessed. Radiographic evidence of errors include obturation short It is important to understand that the obturation as assessed on
or beyond the desired working length and voids in the obturation. a postoperative periapical radiograph may also reflect the quality
Fig. 15.22 Specialized heated pluggers available in a variety of tapers

are advocated for use in the continuous wave of condensation technique.
(Courtesy Kerr Endodontics.)
A
B
Fig. 15.24 Specialized ovens are used to heat obturators, softening the
gutta-percha surrounding the core. (A) The GuttaCore oven is marketed for
use with GuttaCore obturators and has two arms that are pressed down to
move the obturator into the heating chamber. (Courtesy Dentsply Sirona.)
(B) The Soft-Core Heater is marketed for use with Soft-Core obturators and
holds up to four obturators at once. (Courtesy Kerr Endodontics.)
but the master apical file radiograph shows the master file to the
correct working length, this indicates an obturation error. How-
ever, if the master apical file radiograph also shows the file short of
working length, this indicates an instrumentation error.
The ideal research design to compare obturation techniques
or materials would be a prospective, randomized clinical trial
evaluating the outcomes of endodontic treatment after the use of
two different techniques or materials. Unfortunately, such out-
comes studies do not exist in the endodontic literature and are
unlikely to be conducted. The feasibility of such research is poor
as a result of the very large sample size needed to have adequate
Fig. 15.23 The chloroform-dipped master gutta-percha cone is seated to power to detect small differences in outcomes and poor recall
working length and removed. The cone should show an impression of the
rates, especially long-term recall rates needed to obtain valu-
apical preparation of the canal.
able data. The outcomes studies available in the literature largely
report outcomes of a specific technique, or show no significant
of instrumentation. That is, inadequate instrumentation will be difference between contemporary obturation techniques.69,70,87␣
manifest radiographically as inadequate obturation (e.g., a canal
that has been instrumented short will also be filled short). In some Length of Obturation—Outcomes Studies
cases, serial radiographs can be used to troubleshoot if an error
occurred during instrumentation or obturation. For example, if a The ideal length to which canals should obturated has long been a
master cone radiograph shows the cone short of working length, subject of debate in endodontics.95 The level of obturation should
A B
C D
E
Fig. 15.25 This patient presented with pain in the maxillary left posterior and percussion sensitivity on
tooth #14. (A) The preoperative periapical radiograph shows that tooth #14 has been previously endodon-
tically treated, and the obturation of the MB root appears short. (B) The sagittal view of the CBCT image
shows a large periapical radiolucency. (C and D) Both the axial and coronal views show a missed MB2
canal. (E) The postoperative radiograph after nonsurgical retreatment shows two canals treated in the MB
root. MB, Mesiobuccal; CBCT, cone beam computed tomography. (Courtesy Dr. Randy Ball.)
be consistent with the level of instrumentation. Clinicians’ prefer- to a longer length is to ensure that the most apical extent of the
ences vary between treating to the radiographic apex or the “fora- canal has been cleaned. The rationale for instrumenting and obtu-
men” reading on an electronic apex locator, or 0.5 to 1 mm short of rating to a shorter length is to preserve the integrity of the periapi-
one of these levels. The rationale for instrumenting and obturating cal tissues and avoid debris extrusion or overfilling the canal.
A B
Fig. 15.26 Intraorifice barrier materials are placed in the coronal 1 to 2 mm of the canal. (A) PermaFlo
Purple flowable composite orifice barrier. The purple color is easily distinguished from dentin. (B) Vitrebond
glass ionomer intraorifice barrier. (Courtesy Dr. Scott Starley.)
Several outcomes studies have investigated the influence of can occur through the obturated root canal system in a relatively
the level of obturation on treatment success. Research supports short amount of time100-103 (Question 15.10).
improved outcomes of root canal therapy when the canal is filled 0 To prevent coronal leakage and subsequent failure of the root
to 2 mm from the radiographic apex.96-98 In a prospective study of canal treatment, intraorifice barriers (also referred to as orifice bar-
the factors affecting outcomes of nonsurgical root canal treatment, riers) are often placed coronal to the root canal filling material.104
the extension of canal cleaning as close as possible to the apical Many dental materials have been investigated as intraorifice barri-
terminus significantly improved periapical healing.69 In a system- ers, but glass ionomer and flowable composite resin are the most
atic review, root filling extending to within 2 mm of the radio- widely used in clinical practice. As obturation is completed, the
graphic apex significantly improved the outcome of root canal gutta-percha is removed to a level 1 to 2 mm apical to the facial
treatment.99 These studies do not assess obturation level in more cementoenamel junction or the floor of the chamber in a molar.
detail than the 0 to 2 mm range, and debate still exists as to the Any excess sealer and debris is removed from the chamber, typi-
ideal instrumentation and obturation length within that range.␣ cally using alcohol-soaked cotton pellets. The chamber is dried.
The intraorifice barrier material is applied in the coronal 1 to 2
mm of the canal using the recommended instructions for the cho-
Temporization sen material (Fig. 15.26). In some cases, the chamber floor is also
covered (Fig. 15.27).␣
Intraorifice Barriers
The success of endodontic therapy depends on removal of bacteria Temporary Filling Materials
from the root canal system and preventing recontamination. Coro-
nal leakage occurs when microorganisms enter the root canal from As stated previously, prevention of coronal leakage is an impor-
a coronal direction and is a major cause of failure of endodontic tant factor in successful endodontic outcomes. The choice of an
treatment.1 Bacteria and their byproducts may then permeate the interim restoration material to seal the access preparation, either
root canal system and extend into the periradicular tissues, result- between endodontic appointments or between completion of
ing in sequelae that include symptomatic or asymptomatic apical root canal therapy and the definitive restoration, is an integral
periodontitis, acute or chronic apical abscess formation, and/or part of a successful endodontic outcome. Temporization may
pain. Further treatment is then needed (retreatment, endodontic be relatively straightforward, as in the case of a single-surface
surgery, or extraction). Recontamination of the root canal system occlusal or lingual access preparation. Temporization may also be
after endodontic therapy may occur if there is a delay in placing more challenging and time-consuming, as in the case of a tooth
the permanent restoration, breakdown of the temporary restora- with extensive caries and/or defective restorations that must be
tion seal, recurrent caries, leaky margins, and/or fracture or loss of removed before endodontic treatment. If one or more proximal
the restoration or tooth structure. Research has shown that leakage surfaces of the tooth are missing after removal of caries and/or
Fig. 15.27 Intraorifice barrier that covers the entire pulp chamber floor in
a molar. This approach would seal the root canals and any furcation canals
against leakage.
Fig. 15.28 Occlusal access cavity filled with Cavit as a temporary restora-
defective restorations, it may be necessary to restore the tooth with
tion on a mandibular premolar.
a temporary buildup material, either at the start of treatment or
at the end of the appointment. If adequate isolation is not achiev-
able after caries removal, then the tooth must be built up before
continuing with root canal therapy. This allows for easier isolation
of the tooth and prevention of salivary contamination when the
caries are deep. It also allows for the ideal access preparation to cre-
ate a reservoir to contain irrigant during treatment. The decision
to wait until the end of the appointment to build up the missing
walls has the advantage of saving time at the beginning of the
appointment. This approach may also allow more light into the
access for better visibility, and in some cases, it may make it easier
for the clinician to insert files into the tooth during treatment
(e.g., in the case of a missing mesial wall of a maxillary molar).
Cavit (ESPE, Seefeld, Germany) is a very popular tempo-
rary filling material that has been found to prevent leakage in
numerous studies when used to close endodontic access prepara-
tions.105-112 Cavit is premixed and is easily introduced into the
access cavity, as well as easy to remove from the access cavity at the
subsequent appointment (Fig. 15.28). Cavit contains zinc oxide,
calcium sulfate, zinc sulfate, glycol acetate, polyvinyl acetate resin,
polyvinylchloride-acetate, triethanolamine, and red pigment.105
The calcium sulfate is hydrophilic, causing the hydroscopic expan-
sion of the material. This absorption of moisture and expansion
causes the Cavit to seal very well as it sets in a moist environment. Fig. 15.29 Tooth #15 was diagnosed with symptomatic irreversible pul-
A depth of at least 3.5 mm of Cavit is needed to adequately seal pitis and symptomatic apical periodontitis. The tooth had deep mesial
an access preparation (Video 15.3).113 recurrent caries, which needed to be removed before root canal therapy.
TERM (Dentsply Sirona, York, PA/L.D. Caulk Division, Mil- A temporary buildup was completed using Fuji TRIAGE glass ionomer, to
ford, DE) is a composite resin interim restorative material for facilitate isolation during root canal therapy. PermaFlo Purple covers the
endodontics. It is a visible light cured resin containing urethane pulp chamber floor as an intraorifice barrier after the completion of obtura-
dimethacrylate polymers, inorganic radiopaque filler, pigments, and tion. (Courtesy Dr. Kyle Countryman.)
initiators.105 If 3.5 mm of space does not exist for a temporary fill-
ing material, TERM may provide a superior temporary restoration Milford, CT), and Systemp inlay (Vivadent, Schaan, Liechtenstein)
to Cavit. TERM provides an adequate seal at 1, 2, 3, and 4 mm.114 are also temporary filling materials that have been reported to have
REVOTEK LC (GC Corporation, Tokyo, Japan), Tempit (Centrix, good antibacterial and sealing qualities115 (Fig. 15.29).
2. Klevant FJ, Eggink CO: The effect of canal preparation on periapi-

Study Questions
cal disease, Int Endodontic J 16(2):68–75, 1983.
3. Fabricius L, Dahlen G, Sundqvist G, Happonen RP, Moller AJ:
Influence of residual bacteria on periapical tissue healing after che-
momechanical treatment and root filling of experimentally infected
monkey teeth, Eur J Oral Sci 114(4):278–285, 2006.
4. Sjogren U, Figdor D, Persson S, Sundqvist G: Influence of infection
at the time of root filling on the outcome of endodontic treatment
of teeth with apical periodontitis, Int Endodontic J 30(5):297–306,
1997.
5. Manfredi M, Figini L, Gagliani M, Lodi G: Single versus multiple
visits for endodontic treatment of permanent teeth, Cochrane Data-
base Syst Rev 12:CD005296, 2016.
6. Schwendicke F, Gostemeyer G: Single-visit or multiple-visit root
ANSWERS canal treatment: systematic review, meta-analysis and trial sequen-
tial analysis, BMJ Open 7(2):e013115, 2017.
7. De-Deus G, Canabarro A: Strength of recommendation for single-
Answer Box 15 visit root canal treatment: grading the body of the evidence using a
patient-centred approach, Int Endodontic J 50(3):251–259, 2017.
8. Violich DR, Chandler NP: The smear layer in endodontics - a
review, Int Endodontic J 43(1):2–15, 2010.
9. Haapasalo M, Shen Y, Wang Z, Gao Y: Irrigation in endodontics,
Br Dent J 216(6):299–303, 2014.
10. Grossman LI, Oliet S, Del Rio CE: Endodontic practice, Philadel-
phia, 1988, Lea & Febiger.
11. Grossman LI: Endodontics 1776-1976: a bicentennial history
against the background of general dentistry, J Am Dent Assoc
materials to the dentin walls.
93:78–87, 1976.
12. Keane HC: A century of service to dentistry, Philadelphia, 1944, S.S.
White Dental Manufacturing Co.
13. Friedman CM, Sandrik JL, Heuer MA, Rapp GW: Composition
and mechanical properties of gutta-percha endodontic points, J
Dent Res 54(5):921–925, 1975.
14. Bunn CW: Molecular structure of rubber-like elasticity. Part I: the
crystal structure of gutta-percha, rubber and polychloroprene, Proc
R Soc Lond (Biol) 80:40, 1942.
15. Marciano J, Michailesco P, Abadie MJ: Stereochemical structure
characterization of dental gutta-percha, J Endod 19(1):31–34,
1993.
16. Costa GE, Johnson JD, Hamilton RG: Cross-reactivity studies of
gutta-percha, gutta-balata, and natural rubber latex (Hevea brasil-
iensis), J Endod 27(9):584–587, 2001.
17. Hamann C, Rodgers PA, Alenius H, Halsey JF, Sullivan K: Cross-
reactivity between gutta-percha and natural latex: assumption vs.
- reality, J Am Dent Assoc 133:1357–1367, 2002.
- 18. Marciano J, Michailesco P, Charpentier E, Carrera LC, Abadie
MJ: Thermomechanical analysis of dental gutta-percha, J Endod
18(6):263–270, 1992.
19. Schilder H, Goodman A, Aldrich W: The thermomechanical prop-
-
erties of gutta-percha. I. The compressibility of gutta-percha, Oral
Surg Oral Med Oral Pathol 37(6):946–953, 1974.
20. Goodman A, Schilder H, Aldrich W: The thermomechanical prop-
erties of gutta-percha. II. The history and molecular chemistry
of gutta-percha, Oral Surg Oral Med Oral Pathol 37(6):954–961,
1974.
21. Schilder H, Goodman A, Aldrich W: The thermomechanical
properties of gutta-percha. III. Determination of phase transition
temperatures for gutta-percha, Oral Surg Oral Med Oral Pathol
38(1):109–114, 1974.
22. Schilder H, Goodman A, Aldrich W: The thermomechanical proper-
ties of gutta-percha. Part V. Volume changes in bulk gutta-percha as a
function of temperature and its relationship to molecular phase trans-
References formation, Oral Surg Oral Med Oral Pathol 59(3):285–296, 1985.
23. Chogle S, Mickel AK, Huffaker SK, Neibaur B: An in vitro assess-
1. Gillen BM, Looney SW, Gu LS, et al.: Impact of the quality of ment of iodoform gutta-percha, J Endod 31:814–816, 2005.
coronal restoration versus the quality of root canal fillings on suc- 24. Holland R, Murata SS, Dezan E, Garlipp O: Apical leakage after
cess of root canal treatment: a systematic review and meta-analysis, root canal filling with an experimental calcium hydroxide gutta-
J Endod 37(7):895–902, 2011. percha point, J Endod 22:71–73, 1996.
25. Lin S, Levin L, Weiss EI, Peled M, Fuss Z: In vitro antibacterial 48. England MC, West NM, Safavi K, Green DB: Tissue lead levels in
efficacy of a new chlorhexidine slow-release device, Quintessence Int dogs with RC-2B root canal fillings, J Endod 6:728–730, 1980.
37(5):391–394, 2006. 49. Hauman CH, Love RM: Biocompatibility of dental materials used
26. Podbielski A, Boeckh C, Haller B: Growth inhibitory activity of in contemporary endodontic therapy: a review. Part 2. Root canal
gutta-percha points containing root canal medications on common filling materials, Int Endod J 36(3):147–160, 2003.
endodontic bacterial pathogens as determined by an optimized 50. Spangberg LS: Biologic effects of root-canal-filling materials. The effect
in vitro assay, J Endod 26:398–403, 2000. on bone tissue of two formaldehyde-containing root canal pastes: N2
27. Melker KB, Vertucci FJ, Rojas MF, Progulske-Fox A, Belanger M: and Riebler’s paste, Oral Surg Oral Med Oral Pathol 38:934–944, 1974.
Antimicrobial efficacy of medicated root canal filling materials, J 51. Spangberg LS, Langeland K: Biologic effects of dental materials. I.
Endod 32(2):148–151, 2006. Toxicity of root-canal-filling materials on HeLa cells in vitro, Oral
28. Parirokh M, Torabinejad M, Dummer PMH: Mineral trioxide Surg Oral Med Oral Pathol 35:402–414, 1973.
aggregate and other bioactive endodontic cements: an updated 52. FDA explains status of N2 material, J Am Dent Assoc 123(7):236–
overview - part I: vital pulp therapy, Int Endodontic J 51(2):177– 237, 1992.
205, 2018. 53. Council on Dental Therapeutics ADA: The use of root canal filling
29. Torabinejad M, Parirokh M, Dummer PMH: Mineral trioxide materials containing paraformaldehyde: a status report, J Am Dent
aggregate and other bioactive endodontic cements: an updated Assoc 114:95, 1987.
overview - part II: other clinical applications and complications, 54. American Association of Endodontists: Concerning paraformaldehyde-
Int Endodontic J 51(3):284–317, 2018. containing endodontic filling materials and sealers: AAE position state-
30. American Association of Endodontists: Endodontic case difficulty ment. Available from https://www.aae.org/specialty/wp-content/
assessment form and guidelines. Available from www.aae.org. uploads/sites/2/2017/06/paraformaldehydefillingmaterials.pdf 2017.
31. American Association of Endodontists: Endodontic case difficulty 55. Block RM, Lewis RD, Sheats JB, Burke SH: Antibody formation
assessment and referral. endodontics: colleagues for excellence, Chicago, to dog pulp tissue altered by N2-type paste within the root canal, J
IL, 2005, American Association of Endodontists. Endod 8:309–315, 1977.
32. Seltzer S, Green DB, Weiner N, DeRensis F: A scanning EM exam- 56. Block RM, Sheats JB, Lewis RD, Fawley J: Cell-mediated response
ination of silver cones removed from endodontically treated teeth, to dog pulp tissue altered by N2 paste within the root canal, Oral
Oral Surg 33:589–605, 1972. Surg Oral Med Oral Pathol 45:131–142, 1978.
33. Brady JM, Del Rio CE: Corrosion of endodontic silver cones in 57. Block RM, Lewis RB, Sheats JB, Fawley J: Cell-mediated immune
humans: a scanning electron microscope and X-ray microprobe response to dog pulp tissue altered by Kerr (Rickert’s) sealer via the
study, J Endod 1(6):205–210, 1975. root canal, J Endod 4:110–116, 1978.
34. Goldberg F: Relationship between corroded silver points and 58. Torabinejad M, Kettering JD, Bakland LK: Evaluation of systemic
endodontic failure, J Endod 7:224–227, 1981. immunological reactions to AH-26 root canal sealer, J Endod
35. Gutierrez JH, Villena F, Gigoux C, Mujica F: Microscope and 5:196–200, 1979.
scanning electron microscope examination of silver points corro- 59. Harnden DG: Tests for carcinogenicity and mutagenicity, Int
sion caused by endodontic materials, J Endod 8:301–311, 1982. Endod J 14:35–40, 1981.
36. Kehoe JC: Intracanal corrosion of a silver cone producing localized 60. Lewis BB, Chestner SB: Formaldehyde in dentistry: a review of the
argyria, J Endod 10:199–201, 1984. mutagenic and carcinogenic potential, J Am Dent Assoc 103:429–
37. American Association of Endodontists: Use of silver points: AAE 434, 1981.
position statement. Available from https://www.aae.org/specialty/ 61. Grossman LI: Endodontic practice, ed 10, Philadelphia, 1982, Lea
wp-content/uploads/sites/2/2017/06/silverpointsstatement.pdf 2017. & Febiger, p 297.
38. Tay FR, Pashley DH, Yiu CK, et al.: Susceptibility of a polycaprolac- 62. Ingle JI, Newton CW, West JD, et al.: Obturation of the radicular
tone-based root canal filling material to degradation. II. Gravimetric space. In Ingle JI, Bakland LK, editors: Endodontics, ed 5, Hamil-
evaluation of enzymatic hydrolysis, J Endod 31:737–741, 2005. ton, London BC, 2002, Decker Inc.
39. Tay FR, Pashley DH, Williams MC, et al.: Susceptibility of a 63. Martin H, Martin TR: Iodoform gutta-percha: MGP a new end-
polycaprolactone-based root canal filling material to degradation. odontic paradigm, Dent Today 18:76, 1999.
I. Alkaline hydrolysis, J Endod 31(8):593–598, 2005. 64. Sleder FS, Lumley PJ, Bohacek JR: Long-term sealing ability of a
40. Tay FR, Loushine RJ, Weller RN, et al.: Ultrastructural evaluation calcium hydroxide sealer, J Endod 17:541–543, 1991.
of the apical seal in roots filled with a polycaprolactone-based root 65. Spangberg LS, Barbosa SV, Lavigne GD: AH 26 releases formalde-
canal filling material, J Endod 31:514–519, 2005. hyde, J Endod 19:596–598, 1993.
41. Tay FR, Loushine RJ, Monticelli F, et al.: Effectiveness of resin-coated 66. Leonardo MR, da Silva LAB, Filho MT, da Silva RS: Release of
gutta-percha cones and a dual-cured, hydrophilic methacrylate resin- formaldehyde by 4 endodontic sealers, Oral Surg Oral Med Oral
based sealer in obturating root canals, J Endod 31:659–664, 2005. Pathol Oral Radiol Endod 88:221–225, 1999.
42. Tay FR, Hiraishi N, Pashley DH, et al.: Bondability of Resilon 67. Whitworth J: Methods of filling root canals: principles and prac-
to a methacrylate-based root canal sealer, J Endod 32(2):133–137, tices, Endod Topics 12:2–24, 2005.
2006. 68. Orstavik D: Physical properties of root canal sealers: measure-
43. Gesi A, Raffaelli O, Goracci C, Pashley DH, Tay FR, Ferrari M: ment of flow, working time, and compressive strength, Int Endod J
Interfacial strength of Resilon and gutta-percha to intraradicular 16(3):99–107, 1983.
dentin, J Endod 31:809–813, 2005. 69. Ng YL, Mann V, Gulabivala K: A prospective study of the fac-
44. Barborka BJ, Woodmansey KF, Glickman GN, Schneiderman E, tors affecting outcomes of nonsurgical root canal treatment: part 1:
He J: Long-term clinical outcome of teeth obturated with Resilon, periapical health, Int Endodontic J 44(7):583–609, 2011.
J Endod 43(4):556–560, 2017. 70. Peng L, Ye L, Tan H, Zhou X: Outcome of root canal obturation
45. Orstavik D: Materials used for root canal obturation: technical, by warm gutta-percha versus cold lateral condensation: a meta-
biological and clinical testing, Endod Topics 12:25–38, 2005. analysis, J Endod 33(2):106–109, 2007.
46. Schwandt NW, Gound TG: Resourcinol-formaldehyde resin “Rus- 71. American Association of Endodontists Predoctoral Directors Work-
sian Red” endodontic therapy, J Endod 29:435–437, 2003. shop. Unpublished data. Chicago, IL, 2012.
47. Huang FM, Tai K-W, Chou M-Y, Chang Y-C: Cytotoxicity of 72. Kececi AD, Unal GC, Sen BH: Comparison of cold lateral com-
resin-, zinc oxide-eugenol, and calcium hydroxide-based root canal paction and continuous wave of obturation techniques following
sealers on human periodontal ligament cells and permanent V79 manual or rotary instrumentation, Int Endodontic J 38(6):381–
cells, Int Endod J 35:153–158, 2002. 388, 2005.
73. American Dental Association: Revised American National Standard/ 93. Collado-Gonzalez M, Garcia-Bernal D, Onate-Sanchez RE, et al.:
American Dental Association Standard No. 78 Dental Obturating Biocompatibility of three new calcium silicate-based endodontic
Cones, 2013. sealers on human periodontal ligament stem cells, Int Endodontic J
74. Wilson BL, Baumgartner JC: Comparison of spreader penetration 50(9):875–884, 2017.
during lateral compaction of .04 and .02 tapered gutta-percha, J 94. Kapralos V, Koutroulis A, Orstavik D, Sunde PT, Rukke HV:
Endod 29(12):828–831, 2003. Antibacterial activity of endodontic sealers against planktonic bac-
75. Lertchirakarn V, Palamara JEA, Messer HH: Load and strain dur- teria and bacteria in biofilms, J Endod 44(1):149–154, 2018.
ing lateral condensation and vertical root fracture, J Endodont 95. Mounce RE: Mothers, pulp lovers, and apical barbarians, Dent
25(2):99–104, 1999. Today 22(8):58–60, 2003.
76. Schmidt KJ, Walker TL, Johnson JD, Nicoll BK: Comparison of 96. Orstavik D, Qvist V, Stoltze K: A multivariate analysis of the outcome
nickel-titanium and stainless-steel spreader penetration and acces- of endodontic treatment, Eur J Oral Sci 112(3):224–230, 2004.
sory cone fit in curved canals, J Endod 26(1):42–44, 2000. 97. Sjogren U, Hagglund B, Sundqvist G, Wing K: Factors affecting the
77. Holcomb JQ, Pitts DL, Nicholls JI: Further investigation of long-term results of endodontic treatment, J Endod 16(10):498–
spreader loads required to cause vertical root fracture during lateral 504, 1990.
condensation, J Endod 13(6):277–284, 1987. 98. Peak JD, Hayes SJ, Bryant ST, Dummer PM: The outcome of
78. Pitts DL, Matheny HE, Nicholls JI: An in vitro study of spreader root canal treatment. A retrospective study within the armed forces
loads required to cause vertical root fracture during lateral conden- (Royal Air Force), Br Dental J 190(3):140–144, 2001.
sation, J Endod 9(12):544–550, 1983. 99. Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K: Outcome of
79. Schilder H: Filling root canals in three dimensions, Dent Clin primary root canal treatment: systematic review of the literature —
North Am723–744, 1967. Part 2. Influence of clinical factors, Int Endod J 41(1):6–31, 2008.
80. Schilder H: Filling root canals in three dimensions, J Endod 100. Swanson K, Madison S: An evaluation of coronal microleakage in end-
32(4):281–290, 2006. odontically treated teeth. Part I. Time periods, J Endod 13:56–59, 1987.
81. Peters CI, Sonntag D, Peters OA: Homogeneity of root canal fill- 101. Torabinejad M, Ung B, Kettering JD: In vitro bacterial penetra-
ings performed by undergraduate students with warm vertical and tion of coronally unsealed endodontically treated teeth, J Endod
cold lateral techniques, Oral Surg Oral Med Oral Pathol Oral Radiol 16:556–559, 1990.
Endod 110(3):e41–e49, 2010. 102. Magura ME, Kafrawy AH, Brown CE, Newton CW: Human saliva
82. Lee FS, Van Cura JE, BeGole E: A comparison of root surface coronal microleakage in obturated root canals: an in vitro study, J
temperatures using different obturation heat sources, J Endod Endod 17:324–331, 1991.
24(9):617–620, 1998. 103. Khayat A, Lee SJ, Torabinejad M: Human saliva penetration of cor-
83. Lipski M: Root surface temperature rises during root canal obtura- onally unsealed obturated root canals, J Endod 19:458–461, 1993.
tion, in vitro, by the continuous wave of condensation technique 104. Wolcott JF, Hicks ML, Himel VT: Evaluation of pigmented
using System B HeatSource, Oral Surg Oral Med Oral Pathol Oral intraorifice barriers in endodontically treated teeth, J Endod
Radiol Endod 99(4):505–510, 2005. 25(9):589–592, 1999.
84. Buchanan LS: Continuous wave of condensation technique, Endod 105. Barkhordar RA, Stark MM: Sealing ability of intermediate restora-
Prac 1(4):7–10, 1998. 13–16, 18 passim. tions and cavity design used in endodontics, Oral Surg Oral Med
85. Mirfendereski M, Roth K, Fan B, et al.: Technique acquisition in Oral Pathol 69(1):99–101, 1990.
the use of two thermoplasticized root filling methods by inexpe- 106. Beach CW, Calhoun JC, Bramwell JD, Hutter JW, Miller GA:
rienced dental students: a microcomputed tomography analysis, J Clinical evaluation of bacterial leakage of endodontic temporary
Endod 35(11):1512–1517, 2009. filling materials, J Endod 22(9):459–462, 1996.
86. Wong AW, Zhang S, Li SK, Zhang C, Chu CH: Clinical studies 107. Balto H: An assessment of microbial coronal leakage of temporary
on core-carrier obturation: a systematic review and meta-analysis, filling materials in endodontically treated teeth, J Endod 28:762–
BMC Oral Health 17(1):167, 2017. 764, 2002.
87. Chybowski EA, Glickman GN, Patel Y, Fleury A, Solomon E, He 108. Lee YC, Yang SF, Hwang YF, Chueh LH, Chung KH: Micro-
J: Clinical outcome of non-surgical root canal treatment using a leakage of endodontic temporary restorative materials, J Endod
single-cone technique with endosequence bioceramic sealer: a ret- 19(10):516–520, 1993.
rospective analysis, J Endod 44(6):941–945, 2018. 109. Noguera AP, McDonald NJ: A comparative in vitro coronal micro-
88. Silva Almeida LH, Moraes RR, Morgental RD, Pappen FG: Are leakage study of new endodontic restorative materials, J Endod
premixed calcium silicate-based endodontic sealers comparable to 16:523–527, 1990.
conventional materials? A systematic review of in vitro studies, J 110. Kazemi RB, Safavi KE, Spangberg LS: Assessment of marginal sta-
Endod 43(4):527–535, 2017. bility and permeability of an interim restorative endodontic mate-
89. Keles A, Alcin H, Kamalak A, Versiani MA: Micro-CT evalua- rial, Oral Surg Oral Med Oral Pathol 78(6):788–796, 1994.
tion of root filling quality in oval-shaped canals, Int Endodontic J 111. Mayer T, Eickholz P: Microleakage of temporary restorations after
47(12):1177–1184, 2014. thermocycling and mechanical loading, J Endod 23(5):320–322,
90. De-Deus G, Belladonna FG, Silva E, et al.: Micro-CT assessment 1997.
of dentinal micro-cracks after root canal filling procedures, Int End- 112. Teplitsky PE, Meimaris IT: Sealing ability of Cavit and TERM as
odontic J 50(9):895–901, 2017. intermediate restorative materials, J Endod 14:278–282, 1988.
91. Tasdemir T, Er K, Yildirim T, et al.: Comparison of the sealing 113. Webber RT, del Rio CE, Brady JM, Segall RO: Sealing quality
ability of three filling techniques in canals shaped with two differ- of a temporary filling material, Oral Surg Oral Med Oral Pathol
ent rotary systems: a bacterial leakage study, Oral Surg Oral Med 46(1):123–130, 1978.
Oral Pathol Oral Radiol Endod 108(3):e129–e134, 2009. 114. Hansen SR, Montgomery S: Effect of restoration thickness on the
92. Poggio C, Riva P, Chiesa M, Colombo M, Pietrocola G: Compara- sealing ability of TERM, J Endod 19(9):448–452, 1993.
tive cytotoxicity evaluation of eight root canal sealers, J Clin Exp 115. Slutzky H, Slutzky-Goldberg I, Weiss EI, Matalon S: Antibacterial prop-
Dent 9(4):e574–e578, 2017. erties of temporary filling materials, J Endod 32(3):214–217, 2006.
Video 15.1 Obturation
Video 15.2 Obturation with MTA
349.e1
434 C HA P T E R 2 0 Apical Microsurgery
Study Questions Apical Preparation

1. If a nonsurgical symptomatic endodontically treated tooth fails, and Since the introduction of periapical ultrasonic technology in the
the quality of the root canal treatment is unacceptable, what is the early 1990s by Carr, apical preparations have been made with
appropriate first line of treatment? ultrasonic tips.26 A variety of tips and tip configurations have
a. Surgical retreatment been introduced to accommodate virtually any access situation
b. Nonsurgical retreatment
c. Exploratory surgery
(Fig. 20.14). Most ultrasonic tips are .25 mm in diameter and
d. Watch approximately 3 mm in length.
2. Significant advances in endodontic microsurgery include all of the Diamond coated tips are suggested as the last ultrasonic tip to
following except: be used in root-end preparation to avoid intradentin and canal
a. Magnification cracks.27 Furthermore, clinical use of diamond tips has shown that
b. Ultrasonics they are more efficient at removing gutta-percha compared with
c. Impact air handpiece stainless steel tips (Figs. 20.15 and 20.16).
d. Bioceramic root-end filling materials
3. All of the following are contraindications for apical surgery except:
a. Medical or systemic complications Piezosurgery
b. Indiscriminate use of periapical surgery
c. Anatomic factors
Piezosurgery is a bone-cutting modality with rapidly increasing
d. Do not have the skills indications in different surgical fields, including endodontic sur-
4. The surgical flap should be designed to be exactly the size of the gery. The main advantages of piezosurgery include protection of
periapical lesion. soft tissues, optimal visualization of the surgical field, decreased
a. True blood loss, reduced vibration and noise, increased comfort for the
b. False patient, and protection of tooth structures. Some disadvantages
5. To avoid gingival recession and papillae shrinkage in the esthetic zone, of piezosurgery include the initial financial burden associated
submarginal flap is the flap of choice. with the purchase of the device, the long duration of the surgi-
a. True cal procedure, and the fact that the instruction manuals of many
b. False piezoelectric units discourage use of these devices in patients with
implanted cardiac pacemakers.27 The technology was developed in
A B
C D
Fig. 20.7 (A) Feather microsurgical blades. (Courtesy of J. Morita.) (B–D) Application of Feather micro-
surgery blades. (Courtesy of J. Morita.)
CHAPTER 20 Apical Microsurgery 435
Fig. 20.8 PR-1 and PR-2 periosteal elevators.
Fig. 20.11 A comparison of Impact Air 45 and NSK 2:1 nose-cone hand-
piece and surgical length burs.
Fig. 20.9 Impact Air 45 and surgical length bur in close proximity to the
mental nerve 8x.
Fig. 20.12 CX-1 explorer locating an untreated portal of exit (POE) on the
beveled surface of a previously retrofilled root at ×20.
Fig. 20.13 CX-1 explorer locating a crack on the facial surface of a root
at ×20.
Fig. 20.10 Aseptico 7000 motor and NSK 2:1 nose-cone handpiece.
Fig. 20.14 Various ultrasonic tips with different shapes and angles.
Fig. 20.17 Piezosurgery Touch (Mecron, Via Loreta, GE, Italy). The control
panel allows the clinician to choose surgical procedure (power) and irriga-
tion types.
Fig. 20.15 Thermoplasticized gutta-percha spinning around a stainless

steel tip at ×16.
Fig. 20.18 Rhodium micromirror view of the beveled surface of the root
at ×13.
5 mm. Recently introduced micromirrors utilize a rhodium coat-

Fig. 20.16 Thermoplasticized gutta-percha “walking” out of the prepara- ing. Rhodium is extremely hard and durable and is unsurpassed in
tion at ×16. reflectivity, clarity, and brightness. They are front surface, scratch
resistant, and autoclavable (JEDMED, St. Louis, MO) (Fig.
1998 by the Italian oral surgeon Tomaso Vercellotti to overcome 20.18). Before using micromirrors, it was impossible to assess the
the limitations of conventional bone surgery28 (Fig. 20.17).␣ thoroughness of apical preparation. Failure to completely remove
old root canal filling material and debris from the facial wall of the
apical preparation (Fig. 20.19) may lead to facial wall leakage and
Apical Preparation Evaluation eventual failure if not cleaned before placement of an apical seal.
Another development in apical microsurgery has been the intro- Clearly, it is necessary to circumferentially remove all debris from
duction of the surgical micromirror. Micromirrors come in a vari- the apical preparation to satisfy the criteria set forth by Gilheany
ety of shapes and sizes and have diameters ranging from 1 mm to et al. and Ricucci and Siqueira.29,30␣
Fig. 20.19 Micromirror view of gutta-percha and debris on the facial wall Fig. 20.20 Complete regeneration of periapical tissues after using MTA
of the apical preparation at ×16. as a root-end filling material in mokkeys. B, Bone; PDL, periodontal liga-
ment; C, cementum; MTA, mineral trioxide aggregate.
Hemostasis
Before selecting and placing retrofilling materials, it is essential to
have established good hemostasis. Hemostasis begins by obtain-
ing and reviewing the patient’s health questionnaire. Consulta-
tion with the patient’s physician may be necessary. Anesthesia
must be profound with an adequate vasoconstrictor. There are
many hemostatic materials available. Such a list could include fer-
ric sulfate, aluminum chloride, collagen, hemostatic gauze, race-
mic epinephrine, or electro-cautery. When selecting hemostatic
agents, one should consider their effect on hard and soft tissue
and whether their use could compromise healing. For a complete
discussion of local anesthesia see Chapter 8.␣
Selecting Retrofilling Materials

Historically, amalgam was first suggested for retrofillings by Far-
rar and reported in Dental Cosmos in 1884.31 In 1978 Oynick Fig. 20.21 Placing SuperEBA into the apical preparation with a #12
and Oynick showed collagen fibers from the periodontal liga- spoon excavator at ×16.
ment against SuperEBA (Southern Anesthesia and Surgical, West
Columbia, SC) retrofills and possibly into the SuperEBA matrix Mixing, Placing, Condensing, Carving, and
as well and suggested that SuperEBA may promote healing.32
Bioceramics such as ProRoot mineral trioxide aggregate (MTA) Finishing Retrofilling Materials
(Dentsply Tulsa Dental, Tulsa, OK), BioAggregate (Innovative Cement consistency retrofilling materials, such as SuperEBA and
Bioceramix, Vancouver, Canada), EndoSequence Root Repair desiccated intermediate restorative material (IRM), are mixed to
Material (Brasseler USA, Savannah, GA), Grey MTA Plus (Avalon a putty consistency and carried to the apical preparation in small
Biomed, Bradenton, FL), and Biodentine (Septodont USA, Lou- truncated cones 1 mm to 2 mm in size on a #12 spoon excava-
isville, CO) were soon to follow. The class of bioceramics includes tor (Fig. 20.21). Between each aliquot of material, a small plug-
alumina and zirconia, bioactive glass, glass ceramics, coatings and ger (JEDMED Instrument Company, St. Louis, MO) that will
composites, calcium silicates, hydroxyapatite, resorbable calcium fit inside the apical preparation is used to condense the material
phosphates, and radiotherapy glasses. The general class is used for (Fig. 20.22).
joint and tissue replacement and for coating metal implants to Final examination of the retrofilling is performed after the sur-
improve biocompatibility. They are chemically and physically sta- face has been dried with a Stropko Irrigator because it is more
ble in a biologic environment and they chemically bond to dentin. accurate to check the margins of the preparation when the beveled
ProRoot MTA, BioAggregate, EndoSequence Root Repair Mate- surface of the root is dry (Fig. 20.23). Materials such as ProRoot
rial, and Grey MTA Plus all fit this definition. MTA are best delivered to the apical preparation with a carrier-
The question as to whether SuperEBA had different outcomes based system (Fig. 20.24).
than ProRoot MTA was studied by Song et al. and reported as When placing ProRoot MTA, select a carrier that will fit into
a prospective randomized controlled study.33 They reported that the apical preparation (Fig. 20.25). This will avoid spilling mate-
there was no significant difference in the clinical outcomes of rial into the bony crypt. As ProRoot MTA is cohesive to itself but
endodontic microsurgery when SuperEBA and ProRoot MTA only slightly adhesive to the walls of the preparation, care must
were used as root-end filling materials. However, ProRoot MTA be exerted to avoid pulling the material out of the preparation
produces complete periapical regeneration histologically whereas (Fig. 20.26). ProRoot MTA retrofilling is finished by wiping the
SuperEBA is incapable of doing the same thing (Fig. 20.20).␣ beveled surface of the root with a moist cotton pellet (Fig. 20.27).␣
Fig. 20.22 Plugging SuperEBA into the apical preparation with a small Fig. 20.25 MAP carrier placed inside the apical preparation at ×16.
plugger at ×16.
Fig. 20.23 Checking for marginal integrity with a CX-1 explorer at ×20. Fig. 20.26 ProRoot mineral trioxide aggregate (MTA) being pulled out of
the apical preparation at ×16.
Fig. 20.24 Micro Apical Placement System.
Fig. 20.27 Checking the marginal integrity mineral trioxide aggregate

(MTA) after its application at ×20.
Placing Bone Grafts and Membranes

A frequently asked question is whether a bone graft should be
placed in the bony crypt or a membrane placed over the surgi-
cal site as a matter of routine. According to the review paper by
Lin et al., biologically a clot is a better space filler than all bone
grafting materials as it contains the host’s own biologic prod-
uct to provide an excellent scaffold for wound healing. The best
application of membrane barriers in periapical surgery appears
to be in combined endodontic-periodontal lesions or large peri-
apical lesions communicating with the alveolar crest. They also
concluded that there is no conclusive evidence to demonstrate
that the application of membrane barriers in large or through-
and-through bony lesions has a better long-term outcome than
a control group in periapical surgery. If formation of perira-
dicular scaring is anticipated, a membrane can be placed for Fig. 20.28 Corn tissure forceps.
cosmetic reasons.
Dahlin et al. showed complete osseous healing of experimen-
tally induced bone defects in rat jaws occurred after 6 weeks when
polytetrafluorethylene (PTFE) membranes were placed on both
sides of the defect.34 Pecora and Andreana repeated the Dah-
lin study with calcium sulfate as a barrier and found the same
results.35 For further discussion of grafting procedures see the sec-
tion on grafting in Chapter 21.
Flap Closure
The final stage of apical microsurgery is flap closure. Care must
be taken to reapproximate the flap in order to promote healing by
primary intention. Suturing is a critical part of flap closure. There
are several suturing materials available. Parirokh et al. showed sig-
nificantly more bacterial contamination and physical debris with
silk sutures compared with polyvinylidene fluoride (PVDF), a
monofilament suture, at 3, 5, and 7 days post placement.36 How-
ever, PVDF is difficult to handle and needs to be pulled several
times to erase the stiff memory. In addition, patients often com-
plain that the tag ends of the suture are stiff and irritating to the Fig. 20.29 Baraquer needle holder/scissors with suture material engaged
oral mucosa. in the scissor.
Maxima PTFE (Henry Schein, NY, USA) is a PTFE coated
monofilament suture that has handling properties similar to silk
but produces less inflammation and contamination. Postoperative Instructions
Although selection of suture material is important, it is also Both oral and written postoperative instructions should be given
necessary to consider needle design. Reverse cutting needles have to the patient. Instructions should be written in simple, straight-
their cutting surfaces on the convex surface of the needle, making forward language. They should minimize patient anxiety arising
them ideal for suturing gingiva and oral mucosa. Maxima PTFE from normal postoperative symptoms by describing how to pro-
sutures are available with a laser cut premium needle that provides mote healing and comfort.
a smoother transition between the needle and the suture material, A typical list of postoperative instructions is as follows:
further reducing drag and tissue trauma. 1. Some swelling and discoloration are common. Use an ice
Although the Adson tissue forceps can hold the flap firmly pack with moderate pressure on the outside of your face (20
while suturing, newer instruments such as the Corn tissue forceps minutes on and 5 minutes off) until you go to bed tonight.
(Laschal Surgical Inc., Purchase, NY) are designed for precision Application of ice and pressure reduces bleeding and swelling
needle placement (Fig. 20.28). The forceps grasp the tissue and and provides an analgesic effect.
the needle enters the tissue through an opening in the ends of the 2. Some oozing of blood is normal. If bleeding increases, place a
forceps. moistened gauze pad or facial tissues over the area and apply
There are a variety of needle holders available for the clinician. finger pressure for 15 minutes. If bleeding continues, call the
The recently introduced Baraquer needle holder (Laschal Surgical dentist’s office.
Inc., Purchase, NY) (Fig. 20.29) has an additional advantage in 3. Do not lift your lip or cheek to look at the area. The stitches
that it contains a small scissors that can also cut the suture. are tied, and you may tear them out.
Once the sutures are placed, the flap should be compressed 4. Starting tomorrow, dissolve 1 teaspoon of salt in a glass of
with a saline soaked gauze and firm finger pressure for a minimum warm water and gently rinse your mouth three or four times
of 3 minutes. This will lessen the chance for the formation of a daily. Rinsing with a 0.12% chlorhexidine mouthwash may
hematoma under the flap.␣ promote healing. Mouthwashes containing alcohol should be
Study Questions
6. Apical preparation evaluation was not possible before the introduction of:
a. Stainless steel periapical ultrasonic tips
b. Micromirrors
c. Piezosurgery
d. Diamond coated periapical ultrasonic tips
7. The most important factor in controlling bleeding is:
a. The patient’s health questionnaire
b. Ferric sulfate
c. Hemostatic gauze
d. Electro-cautery
8. All of the following are bioceramic retrofilling materials except:
a. ProRoot MTA
b. EndoSequence Root Repair Material
c. Amalgam
d. Grey MTA Plus
Fig. 20.30 Scissors/Forcepts Combo suture removal instrument. 9. According to Lin et al. the best material for a bone graft is:
a. Calcium sulfate
b. Allograft
avoided for the first several days after surgery. Careful brush- c. The patient’s own blood clot
ing is important, but vigorous brushing may damage the area d. Bioactive glass
of surgery. Tonight you should brush and floss all areas except 10. The key to suture removal is:
the surgery site. Tomorrow night you can carefully brush the a. Postoperative instructions
surgery site. b. The healing of the epithelium
5. Proper diet and fluid intake are essential after surgery. Eat a c. Needle size
soft diet and chew on the opposite side of your mouth. Drink c. The choice of the suture material
lots of fluids and eat soft foods such as cottage cheese, yogurt,
eggs, and ice cream.
6. Pain is usually minimal after AS, and strong analgesics are
normally not required. Some discomfort is normal. If pain ANSWERS
medication was prescribed, follow the instructions. If no Answers Box 20
medication was prescribed, take your preferred nonprescrip- 1 b. Nonsurgical retreatment
tion pain remedy if needed. If this is not sufficient, call the 2 c. Impact air handpiece
dentist’s office. 3 d. Do not have the skills
7. If you are a smoker, do not smoke for the first 3 days after the 4 b. False
procedure. 5 a. True
8. If you experience excessive swelling or pain or if you run a 6 b. Micromirrors
fever, call the dentist’s office immediately. 7 a. The patient’s health questionnaire
9. Keep your appointment to have the stitches removed. 8 c. Amalgam
(Sutures are removed 3 to 7 days after surgery.) 9 c. The patient’s own blood clot
10 b. The healing of the epithelium
10. Call the dentist’s office if you have any concerns or questions.␣
Suture Removal
References
The key to suture removal is in the healing of the epithelium.
Harrison and Jurosky reported that a thin epithelial seal was 1. Iqbal MK, Kim S: For teeth requiring endodontic therapy, what are
established in the horizontal incisional wound at 24 hours and the differences in the outcomes of restored endodontically treated
a multilayered epithelial seal was established in the vertical inci- teeth compared to implant-supported restorations? Int J Oral Maxil-
sional wound between 24 and 48 hours.37 Most clinicians would lofac Implants 221(Suppl):96–116, 2007.
2. Torabinejad M, Anderson P, Bader J, et al.: The outcomes of
agree that sutures could be left in place for up to 7 days without endodontic treatment, single implant, fixed partial denture and
causing significant soft tissue irritation. no tooth replacement: a systematic review, JPD 98:285–311,
Recently introduced for suture removal is the Scissors/Forceps 2007.
Combo instrument (Fig. 20.30) (Laschal Surgical Inc., Purchase, 3. Ng YL, Mann V, Gulabivala K: Tooth survival following non-sur-
NY). Safety ended suture scissors (Laschal Surgical Inc., Purchase, gical root canal treatment: a systematic review of the literature, Int
NY) have been designed to remove sutures that are buried in Endod J 43:171–189, 2010.
edematous or hypertrophic tissue.␣ 4. Lazarski MP, Walker 3rd WA, Flores CM, et al.: Epidemiological
evaluation of the outcomes of nonsurgical root canal treatment in
a large cohort of insured dental patients, J Endod 27:791, 2001.
Prognosis 5. Salehrabi R, Rotstein I: Endodontic treatment outcomes in a large
patient population in the USA: an epidemiological study, J Endod
Based on the results of several meta-analyses endodontic microsur- 30:846–850, 2004.
gery enjoys high success rates ranging from 91.4% to 94.4%38-53 6. Chen S, Chueh L, Hsiao CK, et al.: An epidemiologic study of tooth
(see Chapter 22). retention after nonsurgical endodontic treatment in a large popula-
tion in Taiwan, J Endod 33:226–229, 2007.
7. Raedel M, Hartmann A, Bohm S, Walter MH: Three-year out- periodontitis after “one-visit” endodontic treatment, Oral Surg Oral
comes of root canal treatment: mining an insurance database, J Dent Med Oral Pathol Oral Radiol Endod 99(2):231–252, 2005.
43(4):412–417, 2015. 33. Teixeira FB, Sano CL, Gomes BP, et al.: A preliminary in vitro study
8. Bernstein SD, Horowitz AJ, Man M, et al.: Outcomes of endodontic of the incidence and position of the root canal isthmus in maxillary
therapy in general practice: a study by the Practitioners Engaged in and mandibular first molars, Int Endod J 36(4):276–280, 2003.
Applied Research and Learning Network, J Am Dent Assoc 143:478– 34. Mannocci F, Peru M, Sherriff M, et al.: The isthmuses of the mesial
487, 2012. root of mandibular molars: a micro-computed tomographic study,
9. Gilbert GH, Tilashalski KR, Litaker MS, et al.: Outcomes of root Int Endod J 38(8):558–563, 2005.
canal treatment in Dental Practice-Based Research Network prac- 35. Degerness R, Bowles W: Anatomic determination of the mesiobuc-
tices, Gen Dent 58:28–36, 2010. cal root resection level in maxillary molars, J Endod 34(10):1182–
10. Saville MH: Pre-Colombian decoration of teeth in Ecuador, Am 1186, 2008.
Anthropol 15:377–394, 1913. 36. Gutarts R, Nusstein J, Reader A, Beck M: In vivo debridement effi-
11. Andrews RR: Evidence of prehistoric dentistry in Central America, cacy of ultrasonic irrigation following hand-rotary instrumentation
Trans Pan Am Med Cong 2:1872–1873, 1893. in human mandibular molars, J Endod 31(3):166–170, 2005.
12. Frank AL, Glick DH, Patterson SS, Weine FS: Long-term evaluation 37. Abella F, de Ribot J, Doria G, et al.: Applications of piezoelec-
of surgically placed amalgam fillings, J Endod 18(8):391–398, 1992. tric surgery in endodontic surgery: a literature review, J Endod
13. Gutmann JL, Harrison JW: Surgical endodontics. Boston, 1991, 40(3):325–332, 2014.
Blackwell. 38. Baldi D, Menini M, Pera F, et al.: Sinus floor elevation using osteo-
14. Shabahang S: State of the art and science of endodontics, J Am Dent tomes or piezoelectric surgery, Int J Oral Maxillofac Surg 40(5):497–
Assoc 136(1):41–52, 2005. 503, 2011.
15. Veksler AE, Kayrouz GA, Newman MG: Reduction of salivary bac- 39. Walmsley AD, Laird WR, Williams AR: Dental plaque removal
teria by pre-procedural rinses with chlorhexidine 0.12%, J Periodon- by cavitational activity during ultrasonic scaling, J Clin Periodontol
tol 62(11):649–651, 1991. 15(9):539–543, 1988.
16. Lin LM, Gaengler P, Langeland K: Periradicular curettage, Int 40. Farrar JN: Radical and heroic treatment of alveolar abscess by ampu-
Endod J 29(4):220–227, 1996. tation of roots of teeth, with description and application of the can-
17. Nair PN: On the causes of persistent apical periodontitis: a review. tilever crown, The Dental Cosmos 26(3):135–139, 1884.
Int Endod J. 39(4):249–281, 2006. 41. Oynick J, Oynick T: A study of a new material for retrograde fill-
18. Weller RN, Niemczyk SP, Kim S: Incidence and position of the ings, J Endod 4(7):203–206, 1978.
canal isthmus. Part 1. Mesiobuccal root of the maxillary first molar, 42. Song M, Shin SJ, Kim E: Outcomes of endodontic micro-resurgery:
J Endod 21(7):380–383, 1995. a prospective clinical study, J Endod 37(3):316–320, 2011.
19. West JD: The relationship between the three-dimensional endodontic 43. Omnell KA: Electrolytic precipitation of zinc carbonate in the jaw;
seal and endodontic failures, Thesis. Boston University Goldman an unusual complication after root resection, Oral Surg Oral Med
School of Graduate Dentistry, 1975. Oral Pathol 12(7):846–852, 1959.
20. Kim S PG, Rubinstein R: Color atlas of microsurgery in endodontics, 44. Dahlin C, Linde A, Gottlow J, Nyman S: Healing of bone defects by
Philadelphia, 2001, WB Saunders. guided tissue regeneration, Plast Reconstr Surg 81(5):672–676, 1988.
21. Layton CA, Marshall JG, Morgan LA, Baumgartner JC: Evaluation 45. Pecora G, Andreana S, Margarone 3rd JE, et al.: Bone regeneration
of cracks associated with ultrasonic root-end preparation, J Endod with a calcium sulfate barrier, Oral Surg Oral Med Oral Pathol Oral
22(4):157–160, 1996. Radiol Endod 84(4):424–429, 1997.
22. Beling KL, Marshall JG, Morgan LA, Baumgartner JC: Evaluation 46. Parirokh M, Asgary S, Eghbal MJ, et al.: A scanning electron micro-
for cracks associated with ultrasonic root-end preparation of gutta- scope study of plaque accumulation on silk and PVDF suture mate-
percha filled canals, J Endod 23(5):323–326, 1997. rials in oral mucosa, Int Endod J 37(11):776–781, 2004.
23. Min MM, Brown Jr CE, Legan JJ, Kafrawy AH: In vitro evalua- 47. Harrison JW, Jurosky KA: Wound healing in the tissues of the peri-
tion of effects of ultrasonic root-end preparation on resected root odontium following periradicular surgery. I. The incisional wound, J
surfaces, J Endod 23(10):624–628, 1997. Endod 17(9):425–435, 1991.
24. Morgan LA, Marshall JG: A scanning electron microscopic study of 48. Setzer FC, Shah S, Kohli M, et al.: Outcome of endodontic surgery: a
in vivo ultrasonic root-end preparations, J Endod 25(8):567–570, 1999. meta-analysis of the literature—part 1: comparison of traditional root-
25. Rainwater A, Jeansonne BG, Sarkar N: Effects of ultrasonic root- end surgery and endodontic microsurgery, J Endod 36:1757, 2010.
end preparation on microcrack formation and leakage, J Endod 49. Setzer FC, Kohli M, Shah S, et al.: Outcome of endodontic surgery:
26(2):72–75, 2000. a meta-analysis of the literature - part 2: comparison of endodontic
26. Carr G: Microscopes in endodontics, J Calif Dent Assoc 11:55, 1992. microsurgical techniques with and without the use of higher magni-
27. Brent PD, Morgan LA, Marshall JG, Baumgartner JC: Evaluation of fication, J Endod 38:1, 2012.
diamond-coated ultrasonic instruments for root-end preparation, J 50. Tsesis I, Rosen E, Taschieri S, et al.: Outcomes of surgical endodon-
Endod 25(10):672–675, 1999. tic treatment performed by a modern technique: an updated meta-
28. Vercellotti T: Technological characteristics and clinical indications of analysis of the literature, J Endod 39:332, 2013.
piezoelectric bone surgery, Minerva Stomatol 53(5):207–214, 2004. 51. Kohli MR, Berenji H, Setzer FC, et al.: Outcome of endodontic
29. Gilheany PA, Figdor D, Tyas MJ: Apical dentin permeability and surgery: a meta-analysis of the literature-part 3: comparison of end-
microleakage associated with root end resection and retrograde fill- odontic microsurgical techniques with 2 different root-end filling
ing, J Endod 20(1):22–26, 1994. materials, J Endod 44:923, 2018.
30. Ricucci D, Siqueira Jr JF: Biofilms and apical periodontitis: study 52. Torabinejad M, Dinsbach N, Turman M, et al.: Survival of inten-
of prevalence and association with clinical and histopathologic find- tionally replanted teeth and implant-supported single crowns: a sys-
ings, J Endod 36(8):1277–1288, 2010. temic review, J Endod 41:992–998, 2015.
31. Siqueira JF: Reaction of periradicular tissues to root canal treatment: 53. Torabinejad M, Landaez M, Milan M, et al.: Tooth retention
benefits and drawbacks, Endodontic Topics 10:123–147, 2005. through endodontic microsurgery or tooth replacement using single
32. Nair PN, Henry S, Cano V, Vera J: Microbial status of apical root implants: a systematic review of treatment outcomes, J Endod 41:1–
canal system of human mandibular first molars with primary apical 10, 2015.
Video 20.0: Endodontic Surgery Introduction
Video 20.1: Periapical Surgery
Video 20.2: Ochsenbein-Luebke Flap
Video 20.3: Root Amputation
Video 20.4: Hemisection
Video 20.5: Bicuspidization
441.e1
Appendix 1
Summary Table of the Root Numbers of
the Permanent Maxillary Teeth
Blaine Cleghorn, and William Christie
See Appendix 4 for a list of references.
Permanent Maxillary Teeth - Number of Roots

Most Common
Anomaly or
Variation
No. (Number of
No. of of Case Reports in
NUMBER OF ROOTS
Studies References Teeth Brackets)
Most
Common 1 2 3 4 Other
Central 1 Root 100% 7 Rahimi, S et al 2009 (1), 892 Dens evaginatus (17)
incisors Weng, X-L et al 2009 2 roots and 2 canals
(2), Sert, S and Bayirli, (14)
GS 2004 (3), Çaliskan, 1 root and 2 canals
MK et al 1995 (4), (10)
Vertucci, F 1984 (5), Fusion (9)
Pineda, F and Kuttler, Dens invaginatus (7)
Y 1972 (6), Barrett, MT
1925 (7)
Lateral 1 Root 100% 7 Weng, X-L et al 2009 (2), 827 Dens invaginatus
incisors Sert, S and Bayirli, GS (58)
2004 (3), Çaliskan, MK Palatogingival groove
et al 1995 (4), Vertucci, (20)
F 1984 (5), Bjorndal, AM Dens evaginatus
and Skidmore, AE 1983 (talon cusp) (17)
(8), Pineda, F and Kut- 2 roots and 2 canals
tler, Y 1972 (6), Barrett (10)
MT 1925 (7) 1 root and 2 canals
(10)
Canines 1 Root 100% 7 Weng, X-L et al 2009 (2), 842 Dens invaginatus (7)
Sert, S and Bayirli, GS 1 root and 2 canals
2004 (3), Çaliskan, MK (2)
et al 1995 (4), Vertucci, Dens evaginatus
F 1984 (5), Bjorndal, AM (talon cusp) (2)
and Skidmore, AE 1983 2 roots (2)
(8), Pineda, F and Kut-
tler, Y 1972 (6), Barrett
MT 1925 (7)
Continued
471
472 A P P EN D I X 1 Summary Table of the Root Numbers of the Permanent Maxillary Teeth
Most Common
Anomaly or
Variation
No. (Number of
NUMBER OF ROOTS
Most
First pre- 3 roots and 3 canals
molar (26)
Caucasian 2 Roots 37.7% 56.7% 1.9% 3.7% 17 Bürklein, S et al (2017) 4482 Furcation groove
& others (9), Abella, F et al 2015 (palatal of B root)
(exclud- (10), Bulut, DG et al (3)
ing 2015 (11), Gupta, S et al Dens evaginatus (2)
Asian (2015) (12), Dababneh,
& NA R and Rodan, R 2013
Native)* (13), Ng’ang’a, RN et al
2010 (14), Atieh, MA
2008 (15), Awawdeh,
L et al 2008 (16),
Chaparro, AJ et al 1999
(17), Kartal, N et al 1998
(18), Zaatar, EI et al
1997 (19), Pecora, JD
et al 1992 (20), Vertucci,
FJ and Gegauff, A 1979
(21), Carns, EJ and
Skidmore, AE 1973 (22),
Green, D 1973 (23),
Mueller, AH 1933 (24),
Barrett MT 1925 (7)
Asian & NA 1 Root 61.8% 37.6% 0.6% 5 Tian, Y-Y et al 2012 (25), 4981
Native Cheng, XL and Weng,
YL 2008 (26), Loh, HS
et al 1998 (27), Aoki, K
1990 (28), Walker, RT
1987 (29)
All studies 50.4% 46.7% 1.2% 1.7% 22 Bürklein, S et al (2017) (9), 9463
Abella, F et al 2015 (10),
Bulut, DG et al 2015 (11),
Gupta, S et al (2015) (12),
Dababneh, R and Rodan,
R 2013 (13), Ng’ang’a,
RN et al 2010 (14), Atieh,
MA 2008 (15), Awawdeh,
L et al 2008 (16),
Chaparro, AJ et al 1999
(17), Kartal, N et al 1998
(18), Zaatar, EI et al 1997
(19), Pecora, JD et al
1992 (20), Vertucci, FJ
and Gegauff, A 1979 (21),
Carns, EJ and Skidmore,
AE 1973 (22), Green, D
1973 (23), Mueller, AH
1933 (24), Barrett MT
1925 (7), Tian, Y-Y et al
2012 (25), Cheng, XL and
Weng, YL 2008 (26), Loh,
HS et al 1998 (27), Aoki,
K 1990 (28), Walker, RT
1987 (29)
APPENDIX 1 Summary Table of the Root Numbers of the Permanent Maxillary Teeth 473
Most Common
Anomaly or
Variation
No. (Number of
NUMBER OF ROOTS
Most
Second 1 Root 90.5% 8.9% 0.2% 0.4% 12 Elnour, M et al 2016 (30), 9833 3 roots and 3
premo- Abella, F et al 2015 canals (16)
lar (10), Bulut, DG et al Dens evaginatus
2015 (11), Yang, L et al (2)
2014 (31), Zaatar, EI
et al 1997 (19), Pecora,
JD et al 1992 (32),
Sikri, VK and Sikri,
P 1991 (33), Aoki, K
1990 (28), Gorlin, RJ
and Goldman, HM
1970 (34), Mueller, AH
1933 (24), Barrett MT
1925 (7)
First molar 3 Roots 1.8% 2.2% 95.5% 0.2% 1.4% 20 Ghobashy, AM et al 2017 7237 3 roots (MB, DB and
(MB, DB (35), Khademi, A et al Palatal) and 4-5
and Li)* 2017 (36), Martins, JN canals (1-2 MB,
et al 2016 (37), Naseri, DB and 2 Palatal)
M et al 2016 (38), Tian, (26)
X-M et al 2016 (39), 3 roots (MB, DB and
Alrahabi, M and Zafar, Palatal) and 5
MS 2015 (40), Nikolou- canals (2MB, 2DB
daki GE et al 2015 (41), and Palatal) (12)
Singh, S and Pawar, M Taurodontism (10)
2015 (42), Bhuyan, AC Fused roots and
et al 2014 (43), Guo, J C-shaped canal
et al 2014 (44), Rou- (10)
hani, A et al 2014 (45), 4 roots (MB, DB and
Silva, EJ et al 2014 2 Palatal) and 4
(46), Plotino, G et al canals (MB, DB
2013 (47), Zhang, R and 2 Palatal) (9)
et al 2011 (48), Zheng,
Q-H et al 2010 (49),
Pattanshetti, N et al
2008 (50), Rwenyonyi,
CM et al 2007 (51),
al Shalabi, RM et al
2000 (52), Thomas, RP,
Moule, AJ and Bryant,
R 1993 (53), Gray, R
1983 (54), Barrett, MT
1925 (7)
Continued
474 A P P EN D I X 1 Summary Table of the Root Numbers of the Permanent Maxillary Teeth
Most Common
Anomaly or
Variation
No. (Number of
NUMBER OF ROOTS
Most
Second 3 Roots 5.9% 9.1% 77.6% 0.8% 17 Ghobashy, AM et al 2017 6699 4 roots (MB, DB and
molar (MB, DB (35), Khademi, A et al 2 Palatal) and 4
and Li) 2017 (36), Martins, JN canals (MB, DB
et al 2016 (37), Tian, and 2 Palatal) (57)
X-M et al 2016 (39), 3 roots and 4 canals
Nikoloudaki GE et al (MB, DB and 2
2015 (41), Singh, S Palatal canals) (7)
and Pawar, M 2015 3 roots and 5 canals
(42), Zhang, Q et al (3 MB, DB and
2014 (55), Rouhani, A Palatal canals) (3)
et al 2014 (45), Silva,
EJ et al 2014 (46),
Plotino, G et al 2013
(47), Kim, Y et al 2012
(56), Zhang, R et al
2011 (48), Rwenyonyi,
CM et al 2007 (51), al
Shalabi, RM et al 2000
(52), Libfeld, H and
Rotstein, I 1989 (57),
Barrett, MT 1925 (7)
Third 3 Roots 31.2% 24.1% 42.4% 2.2% 0.1% 8 Tomaszewska, IM et al 1072 4 roots (3)
molar (MB, DB 2017 (58), Rawtiya, M C-shaped canal (1)
and Li) et al 2016 (59), Singh,
S and Pawar, M 2015
(42), Sert, S et al 2011
(60), Alavi, AM 2002
(61), Sidow, SJ et al
2000 (62), Guerisoli,
DM et al 1998 (63),
*NA Native = North American Native

*MB = mesiobuccal, DB = distobuccal and Li = lingual.
Appendix 2
Summary Table of the Root Canal
Systems of the Permanent Maxillary
Teeth
Blaine Cleghorn, and Willia m Christie
475
Permanent Maxillary Teeth: Number of Canals
Most Common Anomaly or
No. of No. of Variation (Number of Case
NUMBER OF CANALS
Studies References Teeth Reports In Brackets)
Most
Central 1 Canal 99.1% 0.9%* 9 Da Silva, EJ et al 2016 (64), Altunsoy, M et al 2014 (65), Rahimi, S et al 2009 (1), 2635 Dens evaginatus (17)
incisors Weng, X-L et al 2009 (2), Sert, S and Bayirli, GS 2004 (3), Çaliskan, MK et al 1995 2 roots and 2 canals (14)
*2 or (4), Vertucci, F 1984 (5), Pineda, F and Kuttler, Y 1972 (6), Barrett MT 1925 (7) 1 root and 2 canals (10)
more canals Fusion (9)
Dens invaginatus (7)
Lateral 1 Canal 96.0% 4.0%* 9 Da Silva, EJ et al 2016 (64), Altunsoy, M et al 2014 (65), Weng, X-L et al 2009 (2), 2531 Dens invaginatus (58)
incisors Sert, S and Bayirli, GS 2004 (3), Çaliskan, MK et al 1995 (4), Vertucci, F 1984 (5), Palatogingival groove (20)
*2 or Bjorndal, AM and Skidmore, AE 1983 (8), Pineda, F and Kuttler, Y 1972 (6), Barrett Dens evaginatus (talon cusp)
more canals MT 1925 (7) (17)
2 roots and 2 canals (10)
1 root and 2 canalsa(10)
Canines 1 Canal 95.6% 4.4%* 10 Da Silva, EJ et al 2016 (64), Altunsoy, M et al 2014 (65), Somalinga, NS et al 2014 2815 Dens invaginatus (7)
*2 or (66), Weng, X-L et al 2009 (2), Sert, S and Bayirli, GS 2004 (3), Çaliskan, MK et al 1 root and 2 canals (2)
more canals 1995 (4), Vertucci, F 1984 (5), Bjorndal, AM and Skidmore, AE 1983 (8), Pineda, F Dens evaginatus (talon cusp) (2)
and Kuttler, Y 1972 (6), Barrett MT 1925 (7) 2 roots (2)
First premolar 3 roots and 3 canals (20)
Furcation groove (palatal of B
Caucasian & 2 Canals 11.3% 85.7% 1.7% 1.4% 20 Bürklein, S et al (2017) (9), Abella, F et al 2015 (10), Gupta, S et al (2015) (12), Ok, E 6368
root) (3)
others (ex- et al 2014 (67), Ng’ang’a, RN et al 2010 (14), Weng, X-L et al 2009 (2), Ateih, M 2008
Dens evaginatus (2)
cluding Asian (15), Awawdeh, L et al 2008 (16), Sert, S and Bayirli, GS 2004 (3), Kartal, N et al 1998
& NA Native)* (18), Zaatar, EI et al 1997 (19), Çaliskan, MK et al 1995 (4), Pecora, JD et al 1991
(20), Bellizzi, R and Hartwell, G 1985 (68), Vertucci, F and Gegauff, A 1979 (21), Carns,
EJ and Skidmore, AE 1973 (22), Green, D 1973 (23), Pineda, F and Kuttler, Y 1972 (6),
Mueller, AH 1933 (24), Barrett, MT 1925 (7), Hess, W 1925 (69)
Asian & NA 2 Canals 34.2% 63.2% 0.4% 2.4% 4 Weng, X-L et al 2009 (2), Cheng, XL and Weng, YL 2008 (26), Loh, HS et al 1998 (27), 1574
Native Walker, RT 1987 (204)
All studies 15.8% 81.2% 1.4% 1.6% 24 Bürklein, S et al (2017) (9), Abella, F et al 2015 (10), Gupta, S et al (2015) (12), Ok, E 7942
et al 2014 (67), Ng’ang’a, RN et al 2010 (14), Weng, X-L et al 2009 (2), Ateih, M
2008 (15), Awawdeh, L et al 2008 (16), Cheng, XL and Weng, YL 2008 (26), Sert, S
and Bayirli, GS 2004 (3), Kartal, N et al 1998 (18), Loh, HS et al 1998 (27), Zaatar,
EI et al 1997 (19), Çaliskan, MK et al 1995 (4), Pecora, JD et al 1991 (20), Walker,
RT 1987 (29), Bellizzi, R and Hartwell, G 1985 (68), Vertucci, F and Gegauff, A 1979
(21), Carns, EJ and Skidmore, AE 1973 (22), Green, D 1973 (23), Pineda, F and Kut-
tler, Y 1972 (6), Mueller, AH 1933 (24), Barrett, MT 1925 (7), Hess, W 1925 (69)
Second premolar 1 or 2 47.1% 50.8% 0.8% 1.3% 19 Bürklein, S et al (2017) (9), Elnour, M et al 2016 (30), Abella, F et al 2015 (10), Ok, E et al 5815 3 roots and 3 canals (16)
Canals 2014 (67), Yang, L et al 2014 (31), Jayamisha Raj, UJ and Sumitha, M 2009 (70), Dens evaginatus (2)
Weng, X-L et al 2009 (2), Sert, S and Bayirli, GS 2004 (3), Kartal, N et al 1998 (18),
Zaatar, EI et al 1997 (19), Çaliskan, MK et al 1995 (4), Pecora, JD et al 1992 (32),
Sikri, VK and Sikri, P 1991 (33), Bellizzi, R and Hartwell, G 1985 (68), Vertucci, F 1984
(5), Green, D 1973 (23), Pineda, F and Kuttler, Y 1972 (6), Mueller, AH 1933 (24)
First molar 3 roots (MB, DB and Palatal)
(three roots) and 4-5 canals (1-2 MB,
*2 or more canals DB and 2 Palatal) (26)
MB 2 Canals 40.2% 59.8%* 71 Alrahabi, M and Zafar, MS 2015 (40), Marroquin, B et al 2015 (71), Singh, S and Pawar, 18333 3 roots (MB, DB and Palatal)
M 2015 (42), Bhuyan, AC et al 2014 (43), Kim, Y et al 2013 (72), Gu, Y et al 2011 and 5 canals (2MB, 2DB
(73), Peeters, HH et al 2011 (74), Somma, F et al 2009 (75), Weng, X-L et al 2009 (2), and Palatal) (12)
Abiodun-Solanke, IM et al 2008 (76), Alacam, T et al 2008 (77), Khraisat, A and Smadi, Taurodontism (10)
L 2007 (78), Rwenyonyi, CM et al 2007 (51), Eder, A et al 2006 (79), Smadi, L and Fused roots and C-shaped
Khraisat, A 2006 (80), Jung, I-Y et al 2005 (81), Scott, AE and Apicella, MJ 2004 (82), canal (10)
Sert, S and Bayirli, GS 2004 (3), Alavi, AM et al 2002 (61), Schwarze, T et al 2002 (83), 4 roots (MB, DB and 2 Pala-
Wasti, F et al 2001 (84), al Shalabi, RM et al 2000 (52), Weine, FS et al 1999 (85), Imura, tal) and 4 canals (MB, DB
N et al 1998 (86), Çaliskan, MK et al 1995 (4), Thomas, RP, Moule, AJ and Bryant, R and 2 Palatal) (9)
1993 (53), Pecora, JD et al 1992 (87), Kulild, JC and Peters, DD 1990 (88), Gilles, J and
Reader, A 1990 (89), Vertucci, F 1984 (5), Gray, R 1983 (54), Acosta Vigouroux SA and
Trugeda Bosaans, SA 1978 (90), Seidberg, BH et al 1973 (91), Pineda, F and Kuttler, Y
1972 (6), Sykaras, SN and Economou, PN 1971 (92), Weine, FS 1969 (93), Okamura,
T 1927 (94), Hess, W 1925 (69), Zürcher, E 1925 (95), Moral, H 1914 (96), Ghobashy,
AM et al 2017 (35), Khademi, A et al 2, MS017 (36), Betancourt, P et al 2016 (97),
Coelho, MS et al 2016 (98), Naseri, M et al 2016 (38), Tian, X-M et al 2016 (39), Guo,
J et al 2014 (44), Silva, EJ et al 2014 (46), Abuabara, A et al 2013 (99), Plotino, G et al
2013 (47), Reis, AG et al 2013 (100), Kim, Y et al 2012 (56), Lee, J-H et al 2011 (101),
Zhang, R et al 2011 (48), Zheng, Q-H et al 2010 (49), Abiodun-Solanke, IM et al 2008
(76), Pattanshetti, N et al 2008 (50), Hartwell, G et al 2007 (102), Wolcott, J et al 2002
(103), Buhrley, LJ et al 2002 (104), Sempira, HN and Hartwell, GR 2000 (105), Stropko,
JJ 1999 (106), Zaatar, EI et al 1997 (19), Fogel, HM, Peikoff, MD and Christie, WH 1994
(107), Weller, RN and Hartwell, GR 1989 (108), Neaverth, EJ et al 1987 (109), Hartwell,
G and Bellizzi, R 1982 (110), Pomeranz, HH and, Fishelberg, G 1974 (111), Slowey, RR
1974 (112), Nosonowitz, DM and Brenner, MR 1973 (113), Seidberg, BH et al 1973 (91)
DB 1 Canal 98.6% 1.4%* 33 Ghobashy, AM et al 2017 (35), Naseri, M et al 2016 (38), Tian, X-M et al 2016 (39), 8635
Alrahabi, M and Zafar, MS 2015 (40), Briseno-Marroquin, B et al 2015 (71), Singh,
S and Pawar, M 2015 (42), Bhuyan, AC et al 2014 (43), Guo, J et al 2014 (44),
Silva, EJ et al 2014 (46), Plotino, G et al 2013 (47), Kim, Y et al 2012 (56), Zhang,
R et al 2011 (48), Zheng, Q-H et al 2010 (49), Abiodun-Solanke, IM et al 2008 (76),
Weng, X-L et al 2009 (2), Pattanshetti, N et al 2008 (50), Rwenyonyi, CM et al 2007
(51), Sert, S and Bayirli, GS 2004 (3), Alavi, AM et al 2002 (61), Wasti, F et al 2001
(84), al Shalabi, RM et al 2000 (52), Zaatar, EI et al 1997 (19), Çaliskan, MK et al
1995 (4), Thomas, RP, Moule, AJ and Bryant, R 1993 (53), Pecora, JD et al 1992
(87), Vertucci, F 1984 (5), Gray, R 1983 (54), Hartwell, G and Bellizzi, R 1982 (110),
Acosta Vigouroux SA and Trugeda Bosaans, SA 1978 (90), Pineda, F and Kuttler, Y
1972 (6), Hess, W 1925 (69), Zürcher, E 1925 (95)
Continued
Palatal 1 Canal 99.3% 0.7%* 34 Ghobashy, AM et al 2017 (35), Naseri, M et al 2016 (38), Marceliano-Alves, M et al 8804
2016, Tian, X-M et al 2016 (39), Alrahabi, M and Zafar, MS 2015 (40), Briseno-Marro-
quin, B et al 2015 (71), Singh, S and Pawar, M 2015 (42), Bhuyan, AC et al 2014 (43),
Guo, J et al 2014 (44), Silva, EJ et al 2014 (46), Plotino, G et al 2013 (47), Kim, Y et al
2012 (56), Zhang, R et al 2011 (48), Zheng, Q-H et al 2010 (49), Abiodun-Solanke, IM
et al 2008 (76), Weng, X-L et al 2009 (2), Pattanshetti, N et al 2008 (50), Rwenyonyi,
CM et al 2007 (51), Sert, S and Bayirli, GS 2004 (3), Alavi, AM et al 2002 (61), Wasti,
F et al 2001 (84), al Shalabi, RM et al 2000 (52), Zaatar, EI et al 1997 (19), Çaliskan,
MK et al 1995 (4), Thomas, RP, Moule, AJ and Bryant, R 1993 (53), Pecora, JD et al
1992 (87), Vertucci, F 1984 (5), Gray, R 1983 (54), Hartwell, G and Bellizzi, R 1982
(110), Acosta Vigouroux SA and Trugeda Bosaans, SA 1978 (90), Pineda, F and Kuttler,
Y 1972 (6), Hess, W 1925 (69), Zürcher, E 1925 (95)
Second molar 4 roots (MB, DB and 2 Pala-
(three roots) tal) and 4 canals (MB, DB
*2 or more and 2 Palatal) (57)
canals 3 roots and 4 canals (MB, DB
MB 1 Canal 56.5% 43.5%* 35 Ghobashy, AM et al 2017 (35), Khademi, A et al 2017 (36), Wolf, TG et al 2017 (114), 8059 and 2 Palatal canals) (7)
Betancourt, P et al 2016 (97), Coelho, MS et al 2016 (98), Tian, X-M et al 2016 (39), 3 roots and 5 canals (3 MB,
Singh, S and Pawar, M 2015 (42), Silva, EJ et al 2014 (46), Plotino, G et al 2013 (47), DB and Palatal canals) (3)
Reis, AG et al 2013 (100), Han, X et al 2012 (115), Kim, Y et al 2012 (56), Zhang, R
et al 2011 (48), Weng, X-L et al 2009 (2), Rwenyonyi, CM et al 2007 (51), Sert, S and
Bayirli, GS 2004 (3), Alavi, AM et al 2002 (61), Schwarze, T et al 2002 (83), al Shalabi,
RM et al 2000 (52), Stropko, JJ 1999 (106), Imura, N et al 1998 (86), Zaatar, EI et al
1997 (19), Çaliskan, MK et al 1995 (4), Eskoz, N and Weine, FS 1995 (116), Singh,
C et al 1994 (117), Pecora, JD et al 1992 (87), Kulild, JC and Peters, DD 1990 (88),
Gilles, J and Reader, A 1990 (89), Vertucci, F 1984 (5), Hartwell, G and Bellizzi, R 1982
(110), Pomeranz, HH and Fishelberg, G 1974 (111), Nosonowitz, DM and Brenner, MR
1973 (113), Pineda, F and Kuttler, Y 1972 (6), Hess, W 1925 (69)
DB 1 Canal 99.5% 0.5%* 21 Ghobashy, AM et al 2017 (35), Wolf, TG et al 2017 (114), Tian, X-M et al 2016 (39), 5053
Singh, S and Pawar, M 2015 (42), Silva, EJ et al 2014 (46), Plotino, G et al 2013
(47), Kim, Y et al 2012 (56), Zhang, R et al 2011 (48), Weng, X-L et al 2009 (2),
Rwenyonyi, CM et al 2007 (51), Sert, S and Bayirli, GS 2004 (3), Alavi, AM et al
2002 (61), al Shalabi, RM et al 2000 (52), Zaatar, EI et al 1997 (19), Çaliskan, MK
et al 1995 (4), Singh, C et al 1994 (117), Pecora, JD et al 1992 (87), Vertucci, F
1984 (5), Hartwell, G and Bellizzi, R 1982 (110), Pineda, F and Kuttler, Y 1972 (6),
Hess, W 1925 (69)
Palatal 1 Canal 99.8% 0.2%* 20 Ghobashy, AM et al 2017 (35), Wolf, TG et al 2017 (114), Tian, X-M et al 2016 (39), 5003
Singh, S and Pawar, M 2015 (42), Silva, EJ et al 2014 (46), Plotino, G et al 2013
(47), Kim, Y et al 2012 (56), Zhang, R et al 2011 (48), Weng, X-L et al 2009 (2),
Rwenyonyi, CM et al 2007 (51), Sert, S and Bayirli, GS 2004 (3), Alavi, AM et al
2002 (61), al Shalabi, RM et al 2000 (52), Zaatar, EI et al 1997 (19), Çaliskan, MK
et al 1995 (4), Pecora, JD et al 1992 (87), Vertucci, F 1984 (5), Hartwell, G and Bel-
lizzi, R 1982 (110), Pineda, F and Kuttler, Y 1972 (6), Hess, W 1925 (69)
Third molar 3 canals 9.8% 13.4% 51.5% 20.4% 2.2% 6 Rawtiya, M et al 2016 (59), Singh, S and Pawar, M 2015 (42), Weng, X-L et al 2009 715 4 roots (3)
(2), Alavi, AM 2002 (61), Sidow, SJ et al 2000 (62), Guerisoli, DM et al 1998 (63) C-shaped canal (1)
* NA Native = North American Native
Appendix 3
Summary Table of the Root Numbers of
the Permanent Mandibular Teeth
Permanent Mandibular Teeth: Number of Roots

NUMBER OF ROOTS
Most Common
Anomaly or Variation
(Number of
Most No. of No. of Case Reports
Common 1 2 3 4 Other Studies References Teeth In Brackets)
Central 1 Root 100% 13 Verna, GR et al 2017 (118), 9728 Dens invaginatus (6)
incisors Kamtane, S and Ghodke, M Dens evaginatus (talon
2016 (119), Zhengyan, Y et al cusp) (6)
2016 (120), Kayaoglu, G et al 2 canals (6)
2015 (121), Han, T et al 2014
(122), Lin, Z et al 2014 (123),
Aminsobhani, M et al 2013 (124),
Sert, S and Bayirli, GS 2004
(3), Çaliskan, MK et al 1995 (4),
Vertucci FJ 1974 (125), Madiera
MC and Hetem S 1973 (126),
Pineda F and Kuttler Y 1972 (6),
Barrett MT 1925 (7)
Lateral 1 Root 100% 13 Verna, GR et al 2017 (118), Kamtane, 9664 2 canals (5)
incisors S and Ghodke, M 2016 (119), Dens invaginatus (4)
Zhengyan, Y et al 2016 (120),
Kayaoglu, G et al 2015 (121),
Han, T et al 2014 (122), Lin, Z
et al 2014 (123), Aminsobhani,
M et al 2013 (124), Sert, S and
Bayirli, GS 2004 (3), Çaliskan, MK
et al 1995 (4), Vertucci, FJ 1974
(125), Vertucci, FJ 1974 (125),
Madiera, MC and Hetem, S 1973
(126), Pineda, F and Kuttler, Y
1972 (6), Barrett, MT 1925 (7)
Canines 1 Root 96.7% 3.3% 10 Soleymani, A et al 2017 (127), 16452 2 roots and 2 canals (8)
Shemesh, A et al 2016 (128), 2 roots and 3 canals (3)
Zhengyan, Y et al 2016 (120), 1 root and 2 canals (3)
Kayaoglu, G et al 2015 (121),
Han, T et al 2014 (122), Amin-
sobhani, M et al 2013 (124),
Ouellet, R 1995 (129), Pecora, JD
et al 1993 (130), Alexandersen, V
1963 (131), Barrett, MT 1925 (7)
Continued
479
480 A P P EN D I X 3 Summary Table of the Root Numbers of the Permanent Mandibular Teeth
NUMBER OF ROOTS
Most Common
(Number of
First 1 Root 94.3% 4.8% 0.1% 0.1% 26 Alkaabi, W et al 2017 (132), 14137 3 roots and 3 canals (5)
premolar Bürklein, S et al (2017) (9), Dou, 1 root and 2 canals (5)
L et al 2017 (133), Abraham, 1 root and 3 canals (5)
SB and Gopinath, VK 2015 Dens evaginatus (4)
(134), Bulut, DG et al 2015 (11), 2 roots and 2 canals (3)
Huang, Y-D et al 2015 (135), 3 canals (3)
Kazemipoor, M et al 2015 (136), C-shaped canal (4)
Kazemipoor, M et al 2015 (137),
Kong, L-j et al 2015 (138), Llena,
C et al 2014 (139), Singh, S and
Pawar, M 2014 (140), Alhadainy,
HA 2013 (141), Yang, H et al,
2013 (142), Yu, X et al 2012
(143), Jain, A and Bahuguna,
R 2011 (144), Kheddmat, S
et al 2010 (145) , Awawdeh, LA
and Al-Qudah, AA 2008 (146),
Rahimi, S et al 2007 (147), Iyer,
VH et al 2006 (148), Sert, S and
Bayirli, GS 2004 (3), Zaatar, EI
et al 1997 (19), Çaliskan, MK
et al 1995 (4), Geider, P et al
1989 (149), Vertucci, F 1978
(150), Schulze, C 1970 (151),
Second 1 Root 98.4% 1.4% 0.1% 20 Bürklein, S et al (2017) (9), Bulut, 8002 3 canals (12)
premolar DG et al 2015 (11), Kazemipoor, 2 roots and 2 canals
M et al 2015 (136), Kazemipoor, (11)
M et al 2015 (137), lena, C C-shaped canal (7)
et al 2014 (139), Singh, S and Dens evaginatus (6)
Pawar, M 2014 (140), Bolhari, 3 roots and 3 canals (6)
B et al 2013 (152), Yu, X et al
2012 (143), Parekh, V et al 2011
(153), Rahimi, S et al 2009 (1),
Awawdeh, LA and Al-Qudah,
AA 2008 (146), Rahimi, S et al
2007 (147), Sert, S and Bayirli,
GS 2004 (3), Zaatar, EI et al 1997
(19), Çalișkan, MK et al 1995
(4), Geider, P et al 1989 (149),
Vertucci, F 1978 (150), Zillich,
R and Dowson, J 1973 (154),
Visser, JB 1948 (155), Barrett,
MT 1925 (7)
APPENDIX 3 Summary Table of the Root Numbers of the Permanent Mandibular Teeth 481
NUMBER OF ROOTS
Most Common
(Number of
First molar Radix entomolaris (32)
2 roots and 5 canals
(3M and 2D) (20)
(3M and D) (10)
(2M and 3D) (8)
(3M and 3D) (7)
Caucasian 2 Roots 0.2% 96.3% 3.5% 28 Madani, ZS et al 2017 (156), 9639
& others (M&D) Mohammadzadeh Akhlaghi, N
(excluding et al 2017 (157), Celikten, B et al
Asian & 2016 (158), Martins, JN et al
NA Native) 2016 (37), Rodrigues, CT et al
2016 (159), Peiris, R et al 2015
(160), Chourasia, HR et al 2012
(161), Colak, H et al 2012 (162),
Chandra, SS et al 2011 (163),
Al-Qudah, AA and Awawdeh, LA
2009 (164), Schafer, E et al 2009
(165), Pattanshetti, N et al 2008
(50), Reuben, J et al 2008 (166),
Shahi, s et al 2008 (167), Ahmed,
HA et al 2007 (168), Peiris, R et al
2007 (169), Al-Nazhan, S 1999
(170), Sperber, GH and Moreau,
JL 1998 (171), Zaatar, EI et al
1998 (172), Zaatar, EI et al 1997
(19), Rocha, LF et al 1996 (173),
Younes et al 1990 (174), Curzon,
MEJ 1974 (175), Curzon, MEJ
1973 (176), de Souza-Freitas,
JA et al 1971 (177), Skidmore,
AE and Bjorndal, AM 1971 (178),
Asian & NA 2 Roots 0.4% 77.5% 22.1% 17 Zhang, X et al 2015, Jang, J-K et al 11632
Native (M&D) 2013 (179), Kim, S-Y et al 2013
(180), Zhang, R et al 2011 (181),
Huang, CC et al 2010 (182),
Wang, Y et al 2010 (183), Chen,
G et al 2009 (184) Gulabivala,
K et al 2002 (185), Gulabivala,
K et al 2001 (186), Yew, S and
Chan, K 1993 (187), Morita, M
1990 (188), Harada, Y et al 1989
(189), Onda, S et al 1989 (190),
Walker, R 1988 (191), Reichart,
PA and Metah, D 1981 (192),
Curzon, MEJ 1974 (175), de
Souza-Freitas, JA et al 1971
(177)
Continued
482 A P P EN D I X 3 Summary Table of the Root Numbers of the Permanent Mandibular Teeth
NUMBER OF ROOTS
Most Common
(Number of
All studies 2 Roots 0.3% 86.0% 13.7% 45 Madani, ZS et al 2017 (156), 21271
(M&D) Mohammadzadeh Akhlaghi, N
et al 2017 (157), Celikten, B et al
2016 (158), Martins, JN et al
2016 (37), Rodrigues, CT et al
2016 (159), Peiris, R et al 2015
(160), Chourasia, HR et al 2012
(161), Colak, H et al 2012 (162),
Chandra, SS et al 2011 (163),
Al-Qudah, AA and Awawdeh, LA
2009 (164), Schafer, E et al 2009
(165), Pattanshetti, N et al 2008
(50), Reuben, J et al 2008 (166),
Shahi, s et al 2008 (167), Ahmed,
HA et al 2007 (168), Peiris, R
et al 2007 (169), Al-Nazhan, S
1999 (170), Sperber, GH and
Moreau, JL 1998 (171), Zaatar, EI
et al 1998 (172), Zaatar, EI et al
1997 (19), Rocha, LF et al 1996
(173), Younes et al 1990 (174),
Curzon, MEJ 1974 (175), Curzon,
MEJ 1973 (176), de Souza-
Freitas, JA et al 1971 (177),
Skidmore, AE and Bjorndal, AM
1971 (178), Barrett, MT 1925
(7), Zhang, X et al 2015, Jang,
J-K et al 2013 (179), Kim, S-Y
et al 2013 (180), Zhang, R et al
2011 (181), Huang, CC et al
2010 (182), Wang, Y et al 2010
(183), Chen, G et al 2009 (184)
Gulabivala, K et al 2002 (185),
Gulabivala, K et al 2001 (186),
Yew, S and Chan, K 1993 (187),
Morita, M 1990 (188), Harada,
Y et al 1989 (189), Onda, S et al
1989 (190), Walker, R 1988
(191), Reichart, PA and Metah, D
1981 (192), Curzon, MEJ 1974
(175), de Souza-Freitas, JA et al
1971 (177)
APPENDIX 3 Summary Table of the Root Numbers of the Permanent Mandibular Teeth 483
NUMBER OF ROOTS
Most Common
(Number of
Second 2 Roots 23.2% 53.7% 1.8% 0.1% 27 Madani, ZS et al 2017 (156), Pawar, 13932 C-shaped canal (19)
molar (M&D) AM et al 2017 (193), Akhaghi, Taurodontism (18)
NM et al 2016 (194), Celikten, Fusion with a paramolar
B et al 2016 (158), Kim, SY et al (7)
2016 (195), Martins, JN et al 3 roots (MB, MLi, and D)
2016 (37), Shemesh, A et al and 3 canals (6)
2015 (196), Silva, EJNL et al 1 root and 1 canal (6)
2013 (197), Zare Jahromi, M
et al 2013 (198), Zhang, R et al
2011 (181), Zheng, Q et al 2011
(199), Neelakantan, P et al 2010
(200), Al-Qudah, AA and Awaw-
deh, LA 2009 (164), Rahimi, S
et al 2008 (201), Ahmed, HA
et al 2007 (168), Peiris, R et al
2007 (169), Cheung, LHM et al
2006 (202), Gulabivala, K et al
2002 (185), Gulabivala, K et al
2001 (186), Zaatar, EI et al 1997
(19), Rocha, LF da Costa et al
1996 (173), Manning, SA 1990a
(203), Onda, S et al 1989 (190),
Walker, RT 1988 (204), Weine, FS
et al 1988 (205), Kotoku, K 1985
(206), Barrett, MT 1925 (7)
Third molar 2 Roots 42.8% 53.3% 3.7% 0.1% 0% 10 Somasundaram, P et al 2017 (207), 14001 Highly variable; varia-
(M&D) Park, J-B et al 2013 (208), Kuze- tion is the norm
kanani, M et al 2012 (209), Sert,
S et al 2011 (60), Gulabivala, K
et al 2002 (185), Gulabivala, K
et al 2001 (186), Sidow, SJ et al
2000 (62), Guerisoli, DM et al
1998 (63), Ogiwara, I et al 1981
(210), Barrett, MT 1925 (7)
Appendix 4
Summary Table of the Root Canal
Systems of the Permanent Mandibular
Teeth
Permanent Mandibular Teeth: Number of Canals

Most Common
Anomaly or
Variation (Number
No. of No. of of Case Reports
NUMBER OF CANALS Studies References Teeth In Brackets)
Most
Central 1 Canal 84.3% 15.6% 0.1% 23 Verna, GR et al 2017 (118), Da Silva, EJ 14045 Dens invaginatus
incisors et al 2016 (64), Zhengyan, Y et al 2016 (6)
(120), Kayaoglu, G et al 2015 (121), Dens evaginatus
Altunsoy, M et al 2014 (65), Han, T et al (talon cusp) (6)
2014 (122), Lin, Z et al 2014 (123), Liu, 2 canals (6)
J et al 2014 (211), Aminsobhani, M
et al 2013 (124), Sert, S and Bayirli, GS
2004 (3), Gomes, BP et al 1996 (212),
Çaliskan, MK et al 1995 (4), Karagöz-
Kücükay, I 1994 (213), Walker RT 1988
(214), Kaffee I et al 1985 (215), Bellizzi
R and Hartwell G 1983 (216), Warren,
EM and Laws, AJ 1981 (217), Miyoshi
S et al 1977 (218), Vertucci FJ 1974
(125), Madiera MC and Hetem S 1973
(126), Pineda F and Kuttler Y 1972
(6), Laws AJ 1971 (219), Barrett MT
1925 (7)
Lateral 1 Canal 79.1% 20.8% 0.1% 23 Verna, GR et al 2017 (118), Da Silva, EJ 13748 2 canals (5)
incisors et al 2016 (64), Zhengyan, Y et al 2016 Dens invaginatus
(120), Kayaoglu, G et al 2015 (121), (4)
Altunsoy, M et al 2014 (65), Han, T et al
2014 (122), Lin, Z et al 2014 (123), Liu,
J et al 2014 (211), Aminsobhani, M et al
2013 (124), Sert, S and Bayirli, GS 2004
(3), Gomes, BP et al 1996 (212), Çalis-
kan, MK et al 1995 (4), Walker, RT 1988
(214), Karagöz-Kücükay, I 1994 (213),
Kaffe, I et al 1985 (215), Warren, EM
and Laws, AJ 1981 (217), Bellizzi, R and
Hartwell, G 1983 (216), Miyoshi, S et al
1977 (218), Vertucci, FJ 1974 (125),
Madiera, MC and Hetem, S 1973 (126),
Pineda, F and Kuttler, Y 1972 (6), Laws,
AJ 1971 (219), Barrett, MT 1925 (7)
484
APPENDIX 4 Summary Table of the Root Canal Systems of the Permanent Mandibular Teeth 485
Most Common
Anomaly or
Variation (Number
Most
Canines 1 Canal 91.2% 8.8%* 20 Soleymani, A et al 2017 (127), Da Silva, 14377 2 roots and 2
* 2 or more EJ et al 2016 (64), Shemesh, A et al canals (8)
canals 2016 (128), Zhengyan, Y et al 2016 2 roots and 3
(120), Kayaoglu, G et al 2015 (121), canals (3)
Altunsoy, M et al 2014 (65), Han, 1 root and 2
T et al 2014 (122), Somalinga, NS canals (3)
et al 2014 (66), Aminsobhani, M et al
2013 (124), Vaziri, P et al 2008 (220),
Sert, S and Bayirli, GS 2004 (3), Cal-
iskan, MK et al 1995 (4), Pecora, JD
et al 1993 (130), Kaffee I et al 1985
(215), Vertucci, F 1984 (5), Bellizzi, R
and Hartwell, G 1983 (216), Miyoshi,
S et al 1977 (218), Green, D 1973
(23), Pineda, F and Kuttler, Y 1972
(6), Barrett, MT 1925 (7)
First 1 Canal 72.2% 28.9%* 40 Alkaabi, W et al 2017 (132), Bürklein, 13086 3 roots and
premolar S et al (2017) (9), Dou, L et al 3 canals (5)
* 2 or more 2017 (133), Zhang, D et al 2017 1 root and
canals (221), Abraham, SB and Gopinath, 2 canals (5)
VK 2015 (134), Chen, J et al 2015 1 root and
(222), Huang, Y-D et al 2015 (135), 3 canals (5)
Kazemipoor, M et al 2015 (136), Dens evaginatus
Kazemipoor, M et al 2015 (137), (4)
Llena, C et al 2014 (139), Ok, E et al 2 roots and
2014 (67), Shetty, A et al 2014 (223), 2 canals (3)
Singh, S and Pawar, M 2014 (140), 3 canals (3)
Alhadainy, HA 2013 (141), Liu, N C-shaped canal
et al 2013 (224), Yang, H et al, 2013 (4)
(142), Baroudi, K et al 2012 (225),
Yu, X et al 2012 (143), Jain, A and,
Bahuguna, R 2011 (144), Parekh, V
et al 2011 (153), Rahimi, S et al 2007
(147), Kheddmat, S et al 2010 (145) ,
Velmurugan, N and Sandhya, R 2009
(226), Awawdeh, LA and Al-Qudah,
AA 2008 (146), Lu, T-Y et al 2006
(227), Sert, S and Bayirli, GS 2004
(3), Yoshioka, T et al 2004 (228),
Zaatar, EI et al 1997 (19), Çaliskan,
MK et al 1995 (4), Sabala, CL et al
1994 (229), Baisden, MK et al 1992
(230), Geider, P et al 1989 (149),
Walker, RT 1988 (231), Miyoshi, S
et al 1977 (218), Vertucci, F 1978
(150), Green, D 1973 (23), Zillich, R
and Dowson, J 1973 (154), Pineda,
F and Kuttler, Y 1972 (6), Mueller, AH
1933 (24), Barrett, MT 1925 (7)
Continued
486 A P P EN D I X 4 Summary Table of the Root Canal Systems of the Permanent Mandibular Teeth
Most Common
Anomaly or
Variation (Number
Most
Second 1 Canal 84.2% 15.8%* 25 Bürklein, S et al (2017) (9), Kazemipoor, M 8733 3 canals (12)
premolar et al 2015 (136), Kazemipoor, M et al 2 roots and 2
* 2 or more 2015 (137), Llena, C et al 2014 (139), canals (11)
canals Shetty, A et al 2014 (223), Singh, S C-shaped canal
and Pawar, M 2014 (140), Ok, E et al (7)
2014 (67), Bolhari, B et al 2013 (152), Dens evaginatus
Baroudi, K et al 2012 (225), Yu, X et al (6)
2012 (143), Parekh, V et al 2011 (153), 3 roots and 3
Rahimi, S et al 2009 (1), Awawdeh, LA canals (6)
and Al-Qudah, AA 2008 (146), Rahimi,
S et al 2007 (147), Hasheminia, M and
Hashemi, A 2005 (232), Sert, S and
Bayirli, GS 2004 (3), Zaatar, EI et al
1997 (19), Çalișkan, MK et al 1995 (4),
Geider, P et al 1989 (149), Miyoshi, S
et al 1977 (218), Vertucci, F 1978 (150),
Green, D 1973 (23), Zillich, R and Dow-
son, J 1973 (154), Pineda, F and Kuttler,
Y 1972 (6), Barrett, MT 1925 (7)
First molar Radix entomolaris
(Two (32)
Roots) 2 roots and 5
* 2 or more canals (3M and
canals 2D) (20)
2 roots and 4
canals (3M and
D) (10)
2 roots and 5
canals (2M and
3D) (8)
2 roots and 6
canals (3M and
3D) (7)
Mesial 2 Canals 3.1% 95.7% 1.1% 0.2% 23 Mohammadzadeh Akhlaghi, N et al 2017 6428
(157)Ja, ng, J-K et al 2013 (179), Kim,
S-Y et al 2013 (180), Wang, Y et al 2010
(183), Al-Qudah, AA and Awawdeh,
LA 2009 (164), Reuben, J et al 2008
(166), Jung, I-Y et al 2005 (81), Sert,
S and Bayirli, GS 2004 (3), Gulabivala,
K et al 2002 (185), Gulabivala, K et al
2001 (186), Wasti, F et al 2001 (84),
Al-Nazhan, S 1999 (170), Zaatar, EI et al
1998 (172), Zaatar, EI et al 1997 (19),
Rocha, LF et al 1996 (173), Çaliskan,
MK et al 1995 (4), Yew, S and Chan, K
1993 (187), Goel, NK et al 1990 (233),
Fabra-Campos, H 1985 (234), Vertucci,
F 1984 (5), Hartwell, G and Bellizzi, R
1982 (110), Pineda, F and Kuttler, Y
1972 (6), Skidmore, AE and Bjorndal,
AM 1971 (178)
APPENDIX 4 Summary Table of the Root Canal Systems of the Permanent Mandibular Teeth 487
Most Common
Anomaly or
Variation (Number
Most
Distal 1 Canal 68.7% 31.3%* 24 Mohammadzadeh Akhlaghi, N et al 6569
2017 (157), Wang, Y et al 2010 (183),
Filpo-Perez, C et al 2015 in press (235),
Jang, J-K et al 2013 (179), Kim, S-Y
et al 2013 (180), Al-Qudah, AA and
Awawdeh, LA 2009 (164), Pattanshetti,
N et al 2008 (50), Reuben, J et al 2008
(166), Sert, S and Bayirli, GS 2004 (3),
Gulabivala, K et al 2002 (185), Gula-
bivala, K et al 2001 (186), Wasti, F et al
2001 (84), Al-Nazhan, S 1999 (170),
Zaatar, EI et al 1998 (172), Zaatar, EI
et al 1997 (19), Rocha, LF et al 1996
(173), Çaliskan, MK et al 1995 (4),
Yew, S and Chan, K 1993 (187), Goel,
NK et al 1990 (233), Fabra-Campos,
H 1985 (234), Vertucci, F 1984 (5),
Hartwell, G and Bellizzi, R 1982 (110),
Pineda, F and Kuttler, Y 1972 (6), Skid-
more, AE and Bjorndal, AM 1971 (178)
First molar
(Three
Roots)
* 2 or more
canals
Mesial 2 Canals 2.8% 97.2%* 8 Mohammadzadeh Akhlaghi, N et al 2017 928
(157), Rodrigues, CT et al 2016 (159),
Kim, S-Y et al 2013 (180), Wang, Y et al
2010 (183), Al-Qudah, AA and Awaw-
deh, LA 2009 (164), Gulabivala, K et al
2002 (185), Gulabivala, K et al 2001
(186), Yew, S and Chan, K 1993 (187)
Distobuccal 1 Canal 98.3% 1.7%* 8 Mohammadzadeh Akhlaghi, N et al 2017 928
Kim, S-Y et al 2013 (180), Wang, Y et al
(186), Yew, S and Chan, K 1993 (187)
Distolingual 1 Canal 100% 9 Mohammadzadeh Akhlaghi, N et al 2017 936
Kim, S-Y et al 2013 (180), Chourasia,
HR et al 2012 (161), Wang, Y et al
(186), Yew, S and Chan, K 1993 (187)
Second C-shaped canal (19)
molar (two Taurodontism (18)
roots) Fusion with a
* 2 or more paramolar (7)
canals 3 roots (MB, MLi,
and D) and 3
canals (6)
1 root and 1 canal
(6)
Continued
488 A P P EN D I X 4 Summary Table of the Root Canal Systems of the Permanent Mandibular Teeth
Most Common
Anomaly or
Variation (Number
Most
Mesial 2 Canals 16.5% 84.0%* 14 Akhaghi, NM et al 2016 (194), Kim, SY 3293
et al 2016 (195), Silva, EJNL et al
2013 (197), Neelakantan, P et al 2010
LA 2009 (164), Sert, S and Bayirli,
GS 2004 (3), Gulabivala, K et al 2002
(185), Gulabivala, K et al 2001 (186),
Zaatar, EI et al 1997 (19), Rocha, LF da
Costa et al 1996 (173), Çaliskan, MK
et al 1995 (4), Weine, FS et al 1988
(236), Vertucci, F 1984 (5), Hartwell, G
and Bellizzi, R 1982 (110)
Distal 1 Canal 88.2% 11.8% 14 Akhaghi, NM et al 2016 (194), Kim, SY 3293
et al 2016 (195), Silva, EJNL et al
2013 (197), Neelakantan, P et al 2010
LA 2009 (164), Sert, S and Bayirli,
GS 2004 (3), Gulabivala, K et al 2002
(185), Gulabivala, K et al 2001 (186),
Zaatar, EI et al 1997 (19), Rocha, LF
et al 1996 (173), Çaliskan, MK et al
1995 (4), Weine, FS et al 1988 (205),
Vertucci, F 1984 (5), Hartwell, G and
Bellizzi, R 1982 (110)
Third molar 2-3 Canals 6.9% 32.9% 51.0% 9.3% 2.2% 3 Somasundaram, P et al 2017 (207), 420 Highly variable;
Sidow, SJ et al 2000 (62), Guerisoli, variation is the
DM et al 1998 (63) norm
References 9. Burklein S, Heck R, Schafer E: Evaluation of the root canal anat-

omy of maxillary and mandibular premolars in a selected german
population using cone-beam computed tomographic data, J Endod
1. Rahimi S, Shahi S, Yavari HR, et al.: A stereomicroscopy study of
43(9):1448–1452, 2017.
root apices of human maxillary central incisors and mandibular sec-
10. Abella F, Teixido LM, Patel S, et al.: Cone-beam computed tomogra-
ond premolars in an Iranian population, J Oral Sci 51(3):411–415,
phy analysis of the root canal morphology of maxillary first and second
2009.
premolars in a spanish population, J Endod 41(8):1241–1247, 2015.
2. Weng XL, Yu SB, Zhao SL, et al.: Root canal morphology of per-
manent maxillary teeth in the Han nationality in Chinese Guan- 11. Bulut DG, Kose E, Ozcan G, et al.: Evaluation of root morphology
zhong area: a new modified root canal staining technique, J Endod and root canal configuration of premolars in the Turkish individu-
35(5):651–656, 2009. als using cone beam computed tomography, Eur J Dent 9(4):551–
3. Sert S, Bayirli GS: Evaluation of the root canal configurations of 557, 2015.
the mandibular and maxillary permanent teeth by gender in the 12. Gupta S, Sinha DJ, Gowhar O, et al.: Root and canal morphology of
Turkish population, J Endod 30(6):391–398, 2004. maxillary first premolar teeth in north Indian population using clear-
4. Çalişkan M, Pehlivan Y, Sepetçioğlu F, et al.: Root canal morphol- ing technique: an in vitro study, J Conserv Dent 18(3):232–236, 2015.
ogy of human permanent teeth in a Turkish population, J Endod 13. Dababneh R, Rodan R: Anatomical landmarks of maxillary bifur-
21(4):200–204, 1995. cated first premolars and their influence on periodontal diagnosis
5. Vertucci FJ: Root canal anatomy of the human permanent teeth, and treatment, J Int Acad Periodontol 15(1):8–15, 2013.
Oral Surg Oral Med Oral Pathol 58(5):589–599, 1984. 14. Ng’ang’a RN, Masiga MA, Maina SW: Internal root morphology
6. Pineda F, Kuttler Y: Mesiodistal and buccolingual roentgeno- of the maxillary first premolars in Kenyans of African descent, East
graphic investigation of 7,275 root canals, Oral Surg Oral Med Oral Afr Med J 87(1):20–24, 2010.
Pathol 33(1):101–110, 1972. 15. Atieh MA: Root and canal morphology of maxillary first premolars
7. Barrett M: The internal anatomy of the teeth with special reference in a Saudi population, J Contemp Dent Pract 9(1):46–53, 2008.
to the pulp and its branches, Dent Cosmos 67:581–592, 1925. 16. Awawdeh L, Abdullah H, Al-Qudah A: Root form and canal mor-
8. Bjørndal AM, Skidmore AE: Anatomy and morphology of permanent phology of Jordanian maxillary first premolars, J Endod 34(8):956–
teeth, Iowa City, 1983, University of Iowa College of Dentistry. 961, 2008.
CHAPTER
19 Obturation of Root Canal System
Chapter Outline
Why to Obturate? Sectional Method of Obturation/Chicago Technique
Timing of Obturation McSpadden Compaction/Thermomechanical
Extent of Root Canal Filling Compaction of the Gutta-Percha
Materials Used for Obturation Thermoplasticized Injectable Gutta-Percha Obturation
Methods of Sealer Placement Solid Core Carrier Technique
Obturation Techniques Obturation with Silver Cone
Armamentarium for Obturation Apical Third Filling
Lateral Compaction Technique Postobturation Instructions
Warm Vertical Compaction Technique Repair Following Endodontic Treatment
Temperature Control
Success of endodontic treatment is based on proper diag- History

nosis, treatment planning, biomechanical preparation 1757—Carious teeth were extracted, filled with gold/lead and
followed by obturation. Obturate means to fill the shaped replanted again.
and disinfected canal with a temporary or permanent fill- 1847—Hill’s stopping was developed.
ing material. It can be achieved by using cements, pastes, 1867—CA Bowman claimed to be the first to use gutta-percha
plastics, or solids. Gutta-percha, in its various forms, has for root canal filling.
remained material of choice for obturation. 1883—Perry claimed that he had been using a pointed gold
wire wrapped with some gutta-percha (roots of present day core
Why to Obturate? carrier technique).
1887— SS White Company began to manufacture GP points.
Microorganisms and their byproducts are the major cause
of pulpal and periapical diseases. However, it is difficult
to consistently and totally disinfect root canal systems.
Therefore, the goal of three-dimensional (3-D) obturation is Timing of Obturation
to provide an impermeable fluid tight seal within the entire
root canal system, to prevent oral and apical microleakage. Patient Symptoms
Objectives of obturation are: Sensitivity on percussion—indicates inflammation of peri-
Elimination of coronal leakage of microorganisms or odontal ligament space, hence canal should not be obtu-
potential nutrients to support their growth in dead space rated before the inflammation has subsided.
of root canal system
To confine any residual microorganisms that have sur- Pulp and Periradicular Status
vived the chemomechanical cleaning and shaping, to
prevent their proliferation and pathogenicity Vital Pulp Tissue
To prevent percolation of periapical fluids into the root In case of vital pulp, obturation can be done in single visit
canal system and feeding microorganism after complete cleaning and shaping
278 Textbook of Endodontics
Necrotic Pulp Tissue

Single-visit endodontics can be done if tooth is
asymptomatic
If patient presents with sensitivity on percussion, it
indicates inflammation of periodontal ligament space,
hence canal should be obturated after the inflammation
has subsided.
Purulent Exudates
If obturation is done in tooth with purulent exudate, pres-
sure and subsequent tissue destruction may occur rapidly.
In such cases, calcium hydroxide should be placed as an
intracanal medicament.
Negative Culture Fig. 19.2 Diagrammatic representation of an obturated tooth.

Dependence on negative culture has decreased now filling up to cementodentinal junction (Figs. 19.1 and
because studies have shown that false negative results 19.2)
can give inaccurate assessment of microbial flora; also the So an ideal obturation should
positive results do not indicate the potential pathogenicity Fill the entire root canal three dimensionally as close to
of bacteria. CDJ as possible
Reflect a continuously tapered funnel same as external
root morphology
Extent of Root Canal Filling Radiographically appear as 3-D filling that extends close
to CDJ
Anatomic limit of pulp space is cementodentinal
junction (CDJ) apically and pulp chamber coronally.
Kuttler (1995) described CDJ as minor apical diameter Overextended obturation is vertical dimension of root filling
which ends 0.5 mm short of apical foramen in young beyond the apex (Fig. 19.3).
patients and 0.67 mm short in older patients. According Overfilling is total obturation of root canal system with excess
to Cohen, apical point of termination should be 1 mm material extruding beyond apical foramen (Figs. 19.4A and B).
from the radiographic apex. Radiographically, the root Underfilling is filling of root canal system >2 mm short of
radiographic apex (Fig. 19.5).
canal filling should have appearance of a dense, 3-D
Fig. 19.1 Radiograph showing obturation in maxillary premolar Fig. 19.3 Radiograph showing overextended obturation in
and molars. maxillary central incisor beyond the apex.
Obturation of Root Canal System 279
A B
Figs. 19.4A and B Radiograph showing overfilled: (A) Distal canal of mandibular molar; (B) Maxillary central incisor.
or well tolerated by the tissues in their set state and are used
in conjunction with the core filling material to establish an
adequate seal.
Grossman (1982) grouped acceptable filling materi-
als into plastics, solids, cements, and pastes. He gave the
following 10 requirements for an ideal root canal filling
material:
1. Easily introduced into root canal
2. Seal the canal laterally as well as apically
3. Not shrink after being inserted
4. Impervious to moisture
5. Bacteriostatic or at least do not encourage bacterial
growth
6. Radiopaque
7. Nonstaining the tooth structure
8. Nonirritating
Fig. 19.5 Radiograph showing underfilled canal of mandibular
second premolar. 9. Sterile/easily sterilized immediately before obturation
10. Easily removed from the root canal if necessary
Materials used for root canal obturation are:
Evaluation of obturation Silver cones
Radiographically, an obturated tooth should show Gutta-percha
• Three-dimensionally filled root canal
Custom cones
• Dense radiopaque filling of root canal system
Resilon
• Filling close to apical terminus without overextending
periapically Root canal sealers
But there can be difficulty in radiographic interpretation
due to radiopacity of sealer, overlying bony anatomy and Silver Cones
2-D view.
Jasper (1941) introduced silver cones with same success
rate as gutta-percha and easier to use
Materials Used for Obturation Rigidity provided by the silver cones made them easy to
An ideal root canal filling should be capable of completely place and permitted length control
preventing communication between the oral cavity and per- Due to stiffness of silver cones, these were mainly used
iapical tissue. Root canal sealers should be biocompatible for teeth with fine, tortuous, and curved canals like canals
of maxillary first premolars, mesial canal of mandibular Chemistry

molars It is an isomer of natural rubber and the natural chemical
Since silver cones lack plasticity, these are not used in form of gutta-percha is trans-1,4-polyisoprene. The cis-form
oval canals like single canal premolars and teeth with belongs to latex elastomer.
oval canals in young persons
But nowadays their use has been declined, due to corro- Composition of commercially available gutta-percha (given by
sion caused by them. Presence of traces of copper, nickel, Friedman et al.)
etc. in silver points add up the corrosion • Matrix (organic) Gutta-percha 20%
• Filler (inorganic) Zinc oxide 66%
• Radiopacifiers (inorganic) sulfates Heavy metal 11%
Gutta-Percha • Plasticizers (organic) Waxes or resins 3%
Gutta-percha is derived from two words: In other words
“GETAH”—meaning gum • Organic content − Gutta-percha + waxes = 23%
• Inorganic content − ZnO + metal sulfates = 77%
“PERTJA”—name of the tree in Malay language
Gutta-percha was initially used as a restorative material Phases of gutta-percha
and later developed into an indispensable endodontic fill- Chemically pure gutta-percha exists in two different crys-
ing material. Being biologically inert, resilient, and electric talline forms, that is, α and β, which differ in molecular
insulator, it was used for various purposes such as coating repeat distance and single bond form. Natural gutta-percha
the transatlantic telegraph cable, cores of golf balls, handles coming directly from the tree is in α-form while the most
of knives, splints for holding fractured joints, to control commercial available product is in β-form. These phases
hemorrhage in extracted sockets, in various skin diseases are interconvertible.
such as psoriasis and eczema.
α-Form β-Form
• Brittle at room temperature • Stable and flexible at room
Historical background
• Becomes tacky and flow- temperature
1843—Sir Jose d’Almeida first introduced gutta-percha to Royal able when heated (low • Becomes less adhesive
Society of England. viscosity) and flowable when heated
In Dentistry—Edwin Truman introduced gutta-percha as tem- • Thermoplasticized gutta- (high viscosity)
porary filling material. percha for warm compac- • Gutta-percha points used
1847—Hill introduced Hill’s stopping (a mixture of bleached tion technique is in α-form with cold compaction are
gutta-percha and carbonate of lime and quartz). in β-form
1867—Bowman first used gutta-percha as root canal filling
material.
Properties of Gutta-percha
1883—Perry packed gold wire wrapped with gutta-percha in
root canals. Biocompatibility: It is inert, highly biocompatible
1887—SS White Company started the commercial manufacture Ductility: Depending on phase existence, it is a ductile
of gutta-percha points. material
1893—Rollins used gutta-percha with pure oxide of mercury in Melting point: It is 60°C
root canals. Dimensional stability: Expansion and shrinkage occurs
1914—Callahan softened the gutta-percha by using rosins and due to heating and cooling, otherwise it is dimensionally
then used it for obturation of the root canals. stable material
1959—Ingle and Levine proposed standardization of root canal Ease of handling: It can be used both in α- and β-form
instruments and filling materials. for obturation depending upon handling features
1976—A group evolved into present day ISO for approval of
specification of root canal instruments and filling materials.
ADA specification for gutta-percha points is no. 78
Clinical Considerations
On heating, gutta-percha expands that accounts for its
increased volume which can be compacted into the
Sources root canal
Gutta-percha is a rigid natural latex produced from sap Gutta-percha shrinks as it returns to normal temperature.
of trees of genus Palaquium. These trees are found in So, vertical pressure should be applied in all warm gutta-
Southeast Asia, especially in Malaysia and Indonesia. In percha technique to compensate for volume change
India, these are found in Assam and Western Ghats. when cooling occurs (Schilder et al.)
Aging of gutta-percha causes brittleness because of the Gutta-percha should always be used with sealer and
oxidation process (Fig. 19.6). Storage under artificial cement to seal root canal space as gutta-percha lacks
light also speeds up their deterioration. Brittle gutta- adhering qualities
percha can be rejuvenated by a technique described by Gutta-percha is soluble in certain solvents like chloro-
Sorien and Oliet. In this, gutta-percha is immersed in hot form, eucalyptus oil, etc. This property can be used to
water (55°C) for 1 or 2 s and then immediately immersed plasticize gutta-percha by treating it with the solvent for
in cold water for few seconds better filling in the canal. But it has shown that gutta-
Gutta-percha cannot be heat sterilized. For disinfection percha shrinks (1–2%) when solidified
of gutta-percha points, they should be immersed in 5.25% Gutta-percha also shows some tissue irritation which is
NaOCl for 1 min (Fig. 19.7) due to high content of zinc oxide
After this, gutta-percha should be rinsed in hydrogen
peroxide or ethyl alcohol to remove crystallized NaOCl Current Available Forms of Gutta-percha
before obturation, as these crystallized particles impair Gutta-percha points: Standard cones are of same
the obturation
size and shape as that of ISO endodontic instruments
(Fig. 19.8)
Auxiliary points: Non-standardized cones; perceive
form of root canal
Greater taper gutta-percha points: Available in 4%, 6%,
8%, and 10% taper (Fig. 19.9)
Fig. 19.6 Aging causes gutta-percha to become brittle which

breaks upon bending.
Fig. 19.8 Gutta-percha points.
Fig. 19.7 Sterilization of gutta-percha by immersing in 5.25%

sodium hypochlorite for 1 min. Fig. 19.9 Greater taper gutta-percha points.
Gutta-percha pellets/bars: They are used in thermo-

plasticized gutta-percha obturation, for example, obtura
system
Precoated core carrier gutta-percha: In these stain-
less steel, titanium or plastic carriers are precoated with
α-phase gutta-percha for use in canal, for example,
thermafil (Fig. 19.10)
Syringe systems: These use low viscosity gutta-percha,
for example, α-seal
Gutta flow: In this gutta-percha powder is incorporated
into resin-based sealer (Fig. 19.11)
Gutta-percha sealers like chloropercha and eucoper-
cha: In these, gutta-percha is dissolved in chloroform/
eucalyptol to be used in the canal
Medicated gutta-percha: Calcium hydroxide, iodoform,
or chlorhexidine diacetate containing gutta-percha
Fig. 19.12 Radiograph showing radiopaque gutta-percha.
points
Advantages of gutta-percha
• Compatibility: Adaptation to canal walls
• Inertness: Makes it non reactive material
• Dimensionally stable
• Tissue tolerance
• Radiopacity: Easily recognizable on radiograph (Fig. 19.12)
• Plasticity: Becomes plastic when heated
• Dissolve in some solvents like chloroform, eucalyptus oil,
etc. This property makes it more versatile as canal filling
material
Disadvantages of gutta-percha
• Lack of rigidity: Bending of gutta-percha is seen when lateral
pressure is applied. So, difficult to use in smaller canals
• Easily displaced by pressure
Fig. 19.10 Thermafil gutta-percha.
• Lacks adhesive quality
Medicated Gutta-percha
Calcium hydroxide containing gutta-percha (Fig. 19.13):
These are available in ISO size of 15–140 and are made
by combining 58% of calcium hydroxide in matrix of 42%
gutta-percha. Action of calcium hydroxide is activated by
moisture in canal
Advantages of calcium hydroxide points
Ease of insertion and removal
Minimal or no residue left
Firm for easy insertion
Disadvantages
Short lived action
Radiolucent
Lack of sustained release
Calcium hydroxide plus points
• Along with calcium hydroxide and gutta-percha, they
Fig. 19.11 Gutta flow. contain tenside which reduces the surface tension
Fig. 19.13 Calcium hydroxide containing gutta-percha. Fig. 19.14 Real seal obturation system.
• Due to presence of water soluble components, such

as tenside and sodium chloride, they are three times
more reactive than calcium hydroxide points
• They have superior pH and increases wettability of
canal surface with increased antibacterial property
• They have sustained alkaline pH for one week
Iodoform containing gutta-percha
• Iodoform containing gutta-percha remains inert till it
comes in to contact with the tissue fluids
• On coming in to contact with tissue fluids, free iodine
is released, which is antibacterial in nature
Chlorhexidine diacetate containing gutta-percha
• In this, gutta-percha matrix is embedded in 5%
chlorhexidine diacetate
• This material is used as an intracanal medicament
Resilon (Fig. 19.14)

A resin-based obturation system was introduced as an
alternative to gutta-percha. It consists of a resin core
material (Resilon) composed of polyester, difunctional Fig. 19.15 Custom cone made according to shape of canal.
methacrylate, bioactive glass and radiopaque fillers, and
a resin sealer. Core material is available in conventional
and standardized cones and pellets
Resilon core bonds to resin sealer, which attaches to the Technique involves customization of gutta-percha cones
etched root surface forming a “monoblock.” This results according to the canal shape by:
in a gutta-percha–sealer interface and a tooth–sealer • Softening it in chloroform, eucalyptol, or halothane
interface. This bonding provides a better coronal seal for 1–2 seconds
and may strengthen the root • Heating several large gutta-percha cones and rolling
Resilon is discussed in detail on page no. 290. the mass between two glass slabs until an appropriate
size is obtained
Custom Cones (Fig. 19.15) Softened cone is then placed into the canal and gently
When apical foramen is open or canal is large, a custom packed to the length. This process is repeated until an
cone is made which allows adaptation of the cone to adequate impression of the canal is obtained at the
canal walls and improves the seal prepared length
Root Canal Sealers

Purpose of sealing root canals is to prevent periapical exu-
dates from diffusing into the unfilled part of the canal, to
avoid re-entry and colonization of bacteria and to check
residual bacteria from reaching the periapical tissues.
Therefore to accomplish a fluid tight seal, a root canal sealer
is needed. Though sealer is used only as adjunct material
in obturation, it affects prognosis of endodontic treatment.
Adequate combination of sealing ability and biocompatibil-
ity of root canal sealer is important for a favorable prognosis
of the root canal treatment.
Requirements of an Ideal Root Canal Sealer

According to Grossman, a root canal sealer should be
Tacky when mixed so as to provide good adhesion Fig. 19.16 Sealer fills the space between gutta-percha points.
between it and canal wall
Able to create hermetic seal
Radiopaque so as to be visible on radiograph. According
to ANSI/ADA specification number 57, all endodontic Binding agent: Act as binding agent between obturating
sealers should be at least 2 mm Al more radiopaque than material and dentin walls
dentin or bone As lubricant: When used with semisolid materials, sealer
Of very fine powder particles for optimal mix
acts as a lubricant
Not shrink upon setting
Radiopacity: Due to radiopacity, sealer can be seen
Nonstaining to tooth structure
on radiograph and thus can show presence of auxiliary
Bacteriostatic or atleast do not encourage bacterial
canals, resorptive areas, root fractures, and shape of
growth apical foramen
Set slowly because long working time allows placement
Certain techniques dictate use of particular sealer:
and adjustment of root filling if necessary For example, chloropercha technique uses material as
Insoluble in tissue fluids
sealer as well as a solvent for the master cone. It allows
Nonirritating to periradicular tissue
the shape of normal gutta-percha cone to be altered
Soluble in a common solvent so that it can be removed
according to the shape of the prepared canal
from root canal if required
Stains caused by different sealers Classification

Grossman’s cement, zinc oxide– Orange–red stain Classification of Sealers According
eugenol (ZOE), endomethasone and N2
to their Composition
Diaket and Tubli-Seal Mild pink discoloration
Eugenol
AH-26 Gray color • Silver containing cements:
Riebler’s paste Dark red stain – Kerr sealer (Rickert, 1931)
– Procosol radiopaque silver cement (Grossman,
The following were added to Grossman’s basic 1936)
requirements: • Silver free cements:
It should not provoke an immune response in periradicu-
– Procosol nonstaining cement (Grossman, 1958)
lar tissue – Grossman’s sealer (Grossman, 1974)
It should be neither mutagenic nor carcinogenic
– Tubliseal (Kerr, 1961)
– Wach’s paste (Wach)
Functions of Root Canal Sealers Noneugenol
Antimicrobial agent: Sealers show antibacterial effect • Diaket
which is excreted immediately after its placement • AH-26
Fill in the discrepancies between the obturating mate- • Chloropercha and eucapercha
rial and dentin walls (Fig. 19.16) • Nogenol
• Hydron According to Ingle
• Endofil Cements
• Glass ionomer Pastes
• Polycarboxylate Plastics
• Calcium phosphate cement
Medicated: These sealers have therapeutic properties
and normally used without core materials According to Harty FJ
• Diaket-A 1. ZOE-based
• N2 2. Resin-based: Consists of an epoxy resin base which sets
• Endomethasone upon mixing with an activator. For example, AH-26,
• SPAD Diaket, hydron
• Iodoform paste 3. Gutta percha-based cements consist of solutions
• Riebler’s paste of gutta-percha in organic solvents, for example,
• Mynol cement chloropercha, eupercha
• Ca(OH)2 paste 4. Dentin adhesive materials, like cyanoacrylate cements,
glass ionomer cements, polycarboxylate cements, cal-
Classification According to Grossman cium phosphate, composite materials
Zinc oxide resin cement 5. Materials to which medicaments have been added;
Calcium hydroxide cements these are divided into two groups:
Paraformaldehyde cements i. Those in which strong disinfectants are added to
Pastes decrease possible postoperative pain, like paraform-
aldehyde and corticosteroid preparation
ii. Those in which calcium hydroxide is to induce
According to Cohen cementogenesis and dentinogenesis at foramen,
ADA specification no. 57 classifies endodontic filling mate- thus creating a permanent biological seal. For exam-
rials as follows: ple, calcibiotic root canal sealer (CRCS), sealapex
Type I: Material intended to be used with core material and biocalex.
Subtypes:
• Class 1: Includes materials in the form of powder and
Zinc Oxide Eugenol (ZOE) Sealers
liquid that sets through a nonpolymerizing process
• Class 2: Includes material in the form of two pastes Chisolm in 1873 introduced zinc oxide and oil of clove
that sets through a nonpolymerizing process cement in dentistry.
• Class 3: Includes polymers and resin systems that set Setting reaction: It sets because of a combination of
through polymerization physical and chemical reaction, yielding a hardened mass of
Type II: Material intended to be used with or without zinc oxide embedded in matrix of long sheath-like crystals of
core material or sealer zinc eugenolate. Hardening of the mixture is due to forma-
• Class 1: Powder and liquid nonpolymerizing tion of zinc eugenolate. Presence of free eugenol tends to
• Class 2: Paste and paste nonpolymerizing weaken the set and shows cytotoxicity. Practically, all ZOE
• Class 3: Metal amalgams sealer cements are cytotoxic and invoke an inflammatory
• Class 4: Polymer and resin systems—polymerization response in connective tissue.
Sealer Composition Features Problems

Kerr root canal Powder • Excellent lubricating It stains the tooth due to
sealer or Rickert’s Zinc oxide 34–41.2% properties presence of silver
formula (developed Precipitated silver 25–30.0% • Greater bulk than any other
by Rickert) Oleo resins 30–16% sealer and thus makes it
Thymol iodide 11–12% ideal for warm vertical
Liquid compaction to fill voids,
Oil of clove 78–80% auxiliary canals and irregu-
Canada balsam 20–22% larities present lateral to
gutta-percha cones
Contd...
Contd...

Procosol Powder Precipatated silver leads to
radiopaque-silver • Zinc oxide 45% staining of tooth
cement (Grossman, • Precipitated silver 17%
1936) • Hydrogenated resins 36%
• Magnesium oxide 2%
Liquid
• Eugenol 90%
• Canada balsam 10%
Procosol Powder • Cement hardens in approxi-
nonstaining cement • Zinc oxide (reagent) 40% mately 2 h at room tempe-
(Grossman, 1958) • Staybelite resin 27% rature
• Bismuth subcarbonate 15% • Setting time in canal is less
• Barium sulfate 15% • Begins to set in root canal
Liquid within 10 to 30 min because
• Eugenol 80% of the moisture present in
• Sweet oil of almond 20% dentin
Grossman’s sealer Powder It has plasticity and slow • Due to coarse particle size
• Zinc oxide (reagent) 42 parts setting time (2 h at 37°C) due of resin, vigorous spatula-
• Staybelite resin 27 parts to presence of sodium borate tion is done during mixing
• Bismuth subcarbonate 15 parts anhydrate • Zinc eugenolate is decom-
• Barium sulfate 15 parts posed by water through
• Sodium borate 1 part continuous loss of eugenol,
Liquid which makes it a weak
• Eugenol unstable compound
Wach’s sealer Powder • Increase in thickness of • Odor of liquid
• Zinc oxide 10 g sealer reduces its lubricat- • Sticky due to presence of
• Tricalcium phosphate 2g ing effect. So, it is indicated Canada balsam
• Bismuth subnitrate 3.5 g when there is a possibility
• Bismuth subiodide 0.3 g of overextension beyond
• Heavy magnesium oxide 0.5 g the confines of root canal
Liquid
• Canada balsam 20 mL
• Oil of clove 6 mL
Tubliseal (1961) Base • Because of good lubricat- • Irritant to periapical tissue
• Zinc oxide 57–59% ing property, it is used in • Very low viscosity makes
• Oleo resins 18.5–21.25% cases where it is difficult for extrusion through apical
• Bismuth trioxide 7.5% a master cone to reach api- foramen
• Thymol iodide 3.75–5% cal third of root canal • Short working time
• Oil and waxes 10% • Does not stain the tooth
Catalysts structure
• Eugenol
• Polymerized resin
• Annidalin
Endoflas Powder • It includes the advantages
• Zinc oxide of zinc oxide, iodoform and
• lodoform calcium hydroxide
• Calcium hydroxide • Resorption is only limited
• Barium sulfate to excess material pushed
Liquid periapically
• Eugenol
• Parachlorophenol
Root Canal Sealers without Eugenol
Kloroperka N-Ø Sealers (given by Power

Nyborg and Tullin, 1965) • Canada balsam 19.6%
• Rosin 11.8%
• Gutta-percha 19.6%
• Zinc oxide 49%
Liquid
• Chloroform
Chloropercha mixture of gutta- Canal is flooded with Callahan resin chloroform solution for 2–3 min and gutta-percha cone is
percha (9%) and chloroform 91% placed and compressed laterally and apically with a plugger until it gets dissolved completely
Modified chloropercha methods in the chloroform solution in the root canal. Additional points are added and dissolved in the
Johnston-Callahan method same way
Nygaard-Ostby Consists of Canada balsam; colophonium and zinc oxide powder mixed with chloroform. Here,
canal walls are coated with Kloroperka, cone is dipped in sealer and placed apically
Hydron (Wichterle and Lim, 1960) Rapid setting hydrophilic, plastic material used as sealer without using a core. It is available as
an injectable root canal filling material
Nogenol Developed to overcome the irritating quality of eugenol. Base is ZnO with barium sulfate as
radiopacifier along with vegetable oil. Set is accelerated by hydrogenated rosin, chlorothymol,
and salicylic acid
Appetite root canal sealer Type I • Tricalcium phosphate 80% • Polyacrylic acid 25%
• Hydroxyapatite 20% • Water 75%
Type II • Tricalcium phosphate 52% • Polyacrylic acid 25%
• Iodoform 30%
Type III • Tricalcium phosphate 80% • Polyacrylic acid 25%
• Iodoform 5%
• Bismuth subcarbonate 1%
Resin-Based Sealers

Diaket Powder: • Good adhesion • Toxic in nature
(Schmidt in 1951) • Zinc oxide • Fast setting • Tacky material; so difficult to
• Bismuth phosphate • Stable in nature manipulate
Liquid • Superior tensile strength • If extruded, can lead to fibrous
• Dihydroxy di-chlorodiphenylmethane encapsulation
• B-diketone • Setting is adversely affected by
• Triethanolamine presence of camphor or phenol
• Caproic acid
• Copolymers of vinyl chloride, vinyl
acetate, and vinyl isobutyl ether
AH-26 Powder • Good adhesive property • Allergic/mutagenic potential
(Schroeder, 1957) • Bismuth oxide 60% • Good flow • Silver present in powder causes
• Hexamethylenetetramine 25% • Low toxicity and well toler- discoloration of tooth
• Silver powder 10% ated by periapical tissue
• Titanium oxide 5% • Setting time is 36–48 h at
Liquid body temperature and 5–7
• Bisphenol diglycidyl ether days at room temperature
Contd...
Contd...

AH Plus Paste A contains • Because of color and shade
• Epoxy resins stability, material of choice
• Calcium tungstate where esthetic is required
• Zirconium oxide • Adapts closely to canal walls
• Silica • Minimum shrinkage on
• Iron oxide pigments setting
AH Plus paste B contains
• Aminoadamantane
• Dibenzyldiamine
• Calcium tungstate
• Zirconium oxide
• Silica
• Silicone oil
Fiberfill • Mixture of UDMA, PEGDMA, HDDMA,
(composition Bis-GMA resins
resembles to • Treated barium borosilicate glasses
dentin bonding • Barium sulfate and silica
agents) • Calcium hydroxide and phosphates
• Initiators, stabilizers, pigments
• Benzoyl peroxide
Fiberfill primer A
• Mixture of acetone and active mono-
mer, NTG-GMA magnesium
Fiberfill primer B
• Mixture of acetone and PMGDMA,
HEMA initiator
• Mix equal number of drops of fiberfill
primer A and B and apply to root canal
Calcium Hydroxide Sealers

Sealapex Base • Good therapeutic effect and • In 100% humidity, it takes
• Calcium hydroxide, zinc oxide, biocompatible 3 weeks to final set. It never
calcium oxide, butyl benzene, • Extruded material resorbs in 4–5 sets in a dry atmosphere
fumed silica months • Absorbs water and
Catalyst expands on setting
• Barium sulfate, titanium
dioxide, zinc stearate, isobutyl
salicylate, disalicylate, trisal-
icylate, bismuth trioxide
CRCS Powder • Biocompatible • Extruded sealer is resistant

• Zinc oxide • Takes 3 days to set to resorption by tissue
• Hydrogenated resin • Stable in nature fluids
• Barium sulfate • Little water resorption • It shows minimal antibac-
• Calcium hydroxide terial activity
• Bismuth subcarbonate
Liquid
• Eugenol
• Eucalyptol
Contd...
Contd...
Apexit Plus Base • Excellent tissue tolerance
• Calcium hydroxide/calcium • Durable sealing of the root canal due
oxide, hydrated collophonium, to the slight setting expansion
and fillers • Its easy flowing composition allows
Activator the material to adapt well even to
• Disalicylate, bismuth hydroxide/ morphologically complicated canals
carbonate, bismuth oxide, and • Convenient application (automix
fillers syringe and intra canal tip enable
easy direct application)
• Long working time (mixed Apexit
Plus can be used over 3 h at room
temperature)
Medicated sealers Powder • Corticosteroids are added to • Degree of irritation is
N2 (Sargenti and • Zinc oxide 68.51 g cement separately as hydrocorti- severe with overfilling
Ritcher, 1961) • Lead tetraoxide 12.00 g sone powder or Terra-Cortril when N2 gets pushed into
N2 refers to second • Paraformaldehyde 4.70 g • Continued release of formaldehyde maxillary sinus or man-
nerve (Pulp is referred • Bismuth subcarbonate 2.60 g gas causes prolonged fixation and dibular canal, it can result
to as first nerve). • Bismuth subnitrate 3.70 g antiseptic action in persisting paresthesia
• Titanium dioxide 8.40 g
• Phenylmercuric borate 0.09 g
Liquid
• Eugenol
• Oleum Rosae
• Oleum Lavandulae
Endomethasone Powder • Radiopaque
(composition is • Zinc oxide 100.00 g • Neither resorbable after setting
almost similar to N2) • Bismuth subnitrate 100.00 g nor retractable to allow stable root
• Dexamethasone 0.019 g canal obturation.
• Hydrocortisone 1.60 g • Antiseptic and anti-inflammatory
• Thymol iodide 25.0 g
• Paraformaldehyde 2.20 g
Liquid
Eugenol
Silicone-based • Silicone monomer, silicone-based • Ease of penetration • Cannot be used in pres-
sealers catalyst, bismuth subnitrate filler • Adjustable working time ence of hydrogen peroxide
Endo-fill • Active ingredients are hydroxyl • Low working viscosity • Canal must be absolutely dry
terminated dimethyl polysilox- • Rubbery consistency • Shrinks upon setting but
ane, benzyl alcohol, and hydro- • Nonresorbable has affinity for flowing into
phobic amorphous silica open dentinal tubules
• Catalysts are tetraethyl orthosil- • Difficult to remove from
icate and polydimethylsiloxane the canals
Roeko seal • Main constituent is • Low film thickness, good flow, bio- • Shows 0.2% expansion on
polydimethylsiloxane compatibility, and low solubility setting
Glass ionomer Powder • Shows bonding to dentin • It cannot be removed from
sealer (Ketac-Endo) • Calcium aluminum lanthanum • Optimal flow property root canal if retreatment is
flurosilicate glass required
• Calcium volframate
• Silicic acid
• Pigments
Liquid
• Polyethylene polycarbonic acid/
maleic acid
• Copolymer
• Tartaric acid
• Water
Abbreviation: CRCS: calcibiotic root canal sealer.

Method of Use
Smear layer removal: Sodium hypochlorite should
not be the last irrigant to be used due to compatibility
issues with resins. Use 17% EDTA or 2% chlorhexidine
as a final rinse
Placement of primer: After drying the canal using paper
points, primer is applied up to apex. Use dry paper points
to wick out the excess primer from canal. Primer is very
important because it creates a collagen matrix that
increases the surface area for bonding. Low viscosity
primer also draws the sealer into the dentinal tubules
Placement of sealer: Sealer can be placed into canal
using a lentulo spiral or by coating the master cone
Obturation: Obturate the canals by lateral or warm
vertical compaction
Fig. 19.17 Resilon. Curing: Resilon is cured with a halogen curing light
for 40 s
Coronal restoration: A coronal restoration is done to
seal the access cavity
Resilon (Fig. 19.17) Advantages of epiphany
Resilon (Epiphany, Pentron Clinical Technologies; Biocompatible
Wallingford, CT; RealSeal, SybronEndo; Orange, CA) is Good coronal seal; so less microleakage
developed to overcome the problems associated with gutta- Nontoxic
percha, viz Nonmutagenic
Shrinkage of gutta-percha on cooling Forms monoblock
Gutta-percha does not bind physically to the sealer, Increases resistance to fracture in endodontically treated
it results in gap formation between the sealer and the teeth
gutta-percha
Disadvantage of epiphany
Resilon core shrinks only 0.5% and bonds to sealer by
Does not retain its softness after heating
polymerization, so no gaps are seen. It is biocompatible,
noncytotoxic, and nonmutagenic. The excellent sealing Monoblock Concept
ability of resilon system is attributed to the “monoblock”
which is formed by adhesion of the resilon cone to epiphany Literal meaning of monoblock is a single unit.
sealer, which adheres and penetrates into the dentin walls Monoblock concept means the creation of a solid, bonded,
of root canal system. continuous material from one dentin wall of the canal to
the other. Monoblock phenomenon strengthens the root by
approximately 20%.
Components of Resilon System Classification of monoblock concept based on number
Primer: It is a self-etch primer, which contains a sulfonic of interfaces present between core filling material and
acid terminated functional monomer, HEMA, water, and bonding substrate:
a polymerization initiator Primary: In this, obturation is completely done with core
Resilon sealer: It is a dual-cure, resin-based sealer. Resin material, for example, use of Hydron, MTA, BioGutta as en
matrix contains Bis-GMA, ethoxylated Bis-GMA, UDMA, masse materials (Fig. 19.18A).
and hydrophilic difunctional methacrylates. It contains Secondary: These have two circumferential interfaces,
fillers of calcium hydroxide, barium sulfate, barium glass, one between sealer and the primed dentin and other
bismuth oxychloride, and silica. Total filler content is between the sealer and core material (Fig. 19.18B). For
70% by weight example, resilon-based system.
Resilon core material: It is a thermoplastic synthetic Tertiary: In this, conventional gutta-percha surface is
polymer-based (polyester) core material which contains coated with resin which bonds with the sealer, which further
bioactive glass, bismuth oxychloride, and barium sulfate. bonds to canal walls. So, there are three circumferential
Filler content is 65% by weight interfaces (Fig. 19.18C):
1. Between the sealer and primed dentin Methods of Sealer Placement
2. Between the sealer and coating which has been applied
over gutta-percha to make them bondable to the root Coating the master cone and placing the sealer in canal
surface with a pumping action. (Fig. 19.19)
3. Between the coating and the core material Placing the sealer in canal with a lentulo spiral
For example, EndoRez and Activ GP system. (Fig. 19.20)
Two prerequisites for a monoblock to function as Placing the sealer on master apical file and turning the
mechanically homogenous unit: file counterclockwise (Fig. 19.21)
1. Material should be able to bond strongly and mutually Injecting the sealer with special syringes (Fig. 19.22)
to each other and substrate used for monoblock Sealer placement techniques vary with the status of api-
2. Monoblock material should have same modulus of cal foramen
elasticity as that of substrate (dentin/restoration) If apex is open, only apical one-third of master cone is coated
with sealer to prevent its extrusion into periapical tissues
If apex is closed, any of above techniques can be used
Obturation Techniques
Material of choice for obturation is gutta-percha in con-
junction with sealer. Obturation methods vary by direction
of compaction (lateral/vertical) and/or temperature of
gutta-percha used either cold or warm (plasticized) (Figs.
19.23A and B).
There are two basic procedures:
1. Lateral compaction of cold gutta-percha
2. Vertical compaction of warm gutta-percha
Other methods are the variations of warmed gutta-
A percha technique.
Fig. 19.19 Sealer can be applied in canal by coating it on gutta-

purcha cone.
C
Figs. 19.18A to C (A) Primary monoblock concept; (B) Secondary
monoblock concept; (C) Tertiary monoblock concept. Fig. 19.20 Lentulo spiral for carrying sealer.
Fig. 19.21 Sealer can be placed in canal by applying it on master

apical file and turning counter clockwise.
A B
Figs. 19.23A and B (A) Lateral compaction of gutta-percha;
(B) Vertical compaction of gutta-percha.
• Use of heat softened gutta-percha

– Vertical compaction technique
– System B continuous wave condensation technique
– Lateral/vertical compaction
– Sectional compaction technique
– McSpadden compaction of gutta-percha
– Thermoplasticized gutta-percha technique including
- Obtura II
Fig. 19.22 Injectable syringe for carrying sealer. - Ultrasonic plasticizing
- Ultrafil system
– Solid core obturation technique including
Armamentarium for Obturation - Thermafil system
- Silver point obturation
(Fig. 19.24)
Primary and accessory gutta-percha points
Spreaders and pluggers for compaction of guttapercha Endo block for measuring gutta-percha points
Absorbent paper points for drying the prepared root Endo organizer for arranging gutta-percha and accessory
canal before applying sealer
points of various sizes
Lentulo spirals for placing sealer Heating device like spirit lamp or butane gas torch
Scissors or GP cutter for cutting gutta-percha Heating instrument like ball burnisher, spoon excavator,
Endo gauge for measuring size of gutta-percha
etc.
Root canal obturation with gutta-percha as a filling material Lateral Compaction Technique
can be mainly divided into the following groups:
• Use of cold gutta-percha It is one of the most common methods used for root canal
– Lateral compaction technique obturation. It involves placement of tapered gutta-percha
• Use of chemically softened gutta-percha cones in canal and then compacting them under pressure
– Chloroform against the canal walls using a spreader. A canal should have
– Halothane continuous tapered shape with a definite apical stop, before
– Eucalyptol
it is ready to be filled by this method.
A B C
D E
I
F
G H
Figs. 19.24A to I Armamentarium for obturation: (A) Primary gutta-percha points; (B) Absorbent paper points; (C) Accessory gutta-
percha points; (D) Spreader, plugger and Lentulo spiral; (E) Endo organizer for keeping files and gutta-percha; (F) Endo gauge for
measuring size of gutta-percha; (G) Butane gas torch; (H) Gutta-percha cutter; (I) Scissor.
Technique
Following the canal preparation, select the master gutta-
percha cone whose diameter is same as that of master
apical file. One should feel the tugback with master gutta-
percha point (Fig. 19.25). Master gutta-percha point is
notched at the working distance analogous to the level
of incisal or occlusal edge reference point (Fig. 19.26)
Check the fit of cone radiographically. If found satisfac-
tory, remove the cone from the canal and place it in
sodium hypochlorite:
• If cone fits short of the working length, check for den-
tin chip debris, any ledge, or curve in the canal and
treat them accordingly (Figs. 19.27A and B)
• If cone selected is going beyond the foramen, either
select the larger number cone or cut that cone to the
Fig. 19.25 One should feel tugback with master
working length (Fig. 19.28) gutta-percha cone.
• If cone shows “s” shaped appearance in the radio-
graph, it means cone is too small for the canal. In
that case, a larger cone should be selected to fit in the Select the size of spreader to be used for lateral compac-
canal (Fig. 19.29) tion of that tooth. It should reach 1–2 mm of true working
Fig. 19.26 Notching of gutta-percha at the level Fig. 19.28 If cone is going beyond apical foramen, cut the cone
of reference point. to working length or use larger number cone.
A B
Figs. 19.27A and B (A) Gutta-percha showing tight fit in middle and Fig. 19.29 S-shaped appearance of cone in mesial canal shows
space in apical third; (B) Gutta-percha cone showing tight fit only that cone is too small for the canal, replace it with bigger cone.
on apical part of the canal.
length without binding in the canal should occur, there not by pushing it sideways. It should reach 1–2 mm of the
is a chance for tooth fracture with excessive pressures prepared root length
(Fig. 19.30A). Remove spreader by rotating it back and forth. This com-
Dry the canal with paper points and apply sealer in canal. pacts the gutta-percha and creates a space for accessory
Place master gutta-percha cone in the canal (Fig. 19.30B) cones lateral to the master cone (Figs. 19.30D and E)
Coat the premeasured cone with sealer and place into Place accessory cone in this space and repeat the above
the canal. After master cone placement, place spreader procedure until spreader no longer penetrates beyond
into the canal alongside the cone (Fig. 19.30C). Spreader the cervical line (Fig. 19.30F)
helps in compaction of gutta-percha. It acts as a wedge to Now sever the protruding gutta-percha points at canal
squeeze the gutta-percha laterally under vertical pressure orifice with hot instrument
A B C D E F
Figs. 19.30A to F (A) Check the fit of the spreader; (B) place the master gutta-percha cone in sealer coated canal; (C) place the spreader
alongside the master cone to compact the cone; (D and E) Add accessory cones in the prepared space and repeat the step C to create
space for more accessory cones; (F) Place accessory cone in this space and repeat the above procedure until spreader no longer penetrates
beyond the cervical line.
Advantages
• Can be used in most clinical situations
• Positive dimensional stability of root filling
• During compaction of gutta-percha, it provides length control,
thus decreases the chances of overfilling
Disadvantages
• Presence of voids
• Increased sealer: GP ratio
• Does not produce homogenous mass
• Space may exist between accessory and master cones
(Fig. 19.31)
• Time-consuming
• Less able to seal lateral canals and intracanal defects
Variation in Lateral Compaction Technique

Fig. 19.31 In lateral compaction of gutta-percha, cones never fit as
Use of Vibration, Heat, and Ultrasonics homogeneous mass, sealer occupies the space in between the cones.
An alternative to cold lateral compaction is ultrasonics,
combination of vibration and heat. Lateral compaction
done with alternating heat after placing accessory gutta- Technique (Figs. 19.33A to H)
percha cone can result in better compaction. Root canal is cleaned and shaped properly
Gutta-percha is soluble in number of solvents, namely, Cone is held with a locking tweezer which has been
chloroform, eucalyptol, xylol. This property of gutta-percha adjusted to the working length
is used to adapt it in various canal shapes which are ame- Apical 2–3 mm of cone is dipped into solvent for 3–5 s
nable to be filled by lateral compaction of gutta-percha Softened cone is inserted in the canal with slight apical
technique. pressure until the beaks of locking tweezer touches the
reference point
Indications Here care is taken to keep the canal moistened by irri-
In teeth with blunderbuss canals and open apices. gation, otherwise some of softened gutta-percha may
Root ends with resorptive defects (Figs. 19.32A to J) stick to the desired canal walls, though this detached
In teeth with internal resorption segment can be easily removed by using H-file
A B C
D E F
G H I
Figs. 19.32A to J Esthetic rehabilitation of maxillary central incisor by endodontic

retreatment and crown placement. (A) Preoperative photograph; (B) Preoperative
radiograph; (C) Old gutta-percha removed; (D) working length radiograph; (E)
custom-made gutta-percha cone; (F) Radiograph taken with master cone; (G) MTA
plug given for apical stop; (H) Obturation done using gutta-percha and MTA; (I)
J Postobturation radiograph; (J) Postobturation photograph.
A B C D
E F G H
Figs. 19.33A to H (A) Thoroughly clean and shape the canal; (B) adjust the cone to working length; (C) dip apical 2 to 3 mm of cone into
solvent for 3 to 5 s; (D) Coat the canal with sealer; (E) Place the softened cone in the canal; (F and G) Compact the cone using spreader
and place the accessory gutta-percha cones; (H) Sever the protruding gutta-percha cones using hot burnisher.
Radiograph is taken to verify the fit and correct working Warm Vertical Compaction
length of the cone. When found satisfactory, cone is removed
from the canal and canal is irrigated with sterile water or 99% Technique
isopropyl alcohol to remove the residual solvent Vertical compaction of warm gutta-percha method of filling
After this canal is coated with sealer. Cone is dipped the root canal was introduced by Schilder with an objective
again for 2–3 s in the solvent and thereafter inserted into of filling all the portals of exit with maximum amount of
the canal with continuous apical pressure until the plier gutta-percha and minimum amount of sealer. This is also
touches the reference point known as Schilder’s technique of obturation. In this tech-
A finger spreader is then placed in the canal to compact nique using heated pluggers, pressure is applied in vertical
the gutta-percha laterally direction to heat softened gutta-percha which causes it to
Accessory gutta-percha cones are then placed in the flow and fill the canal space.
space created by spreader Basic requirements of a prepared canal to be filled by
Protruding gutta-percha points are cut at canal orifice vertical compaction technique are
with hot instrument Continuous tapering funnel shape from orifice to apex
Though this method is considered good for adapting (Fig. 19.34)
gutta-percha to the canal walls, chloroform dip fillings Apical opening to be as small as possible so as to prevent
have shown to produce volume shrinkage which may lead extrusion of obturating material
to poor apical seal.
A B C
Fig. 19.34 Canal should be continuous funnel shape from orifice
to apex.
Decreasing the cross-sectional diameter at every

point apically and increasing at each point as canal is
approached coronally
Technique
Select a master cone according to shape and size of the
prepared canal. Cone should fit in 1–2 mm of apical
stop because when softened material moves apically
into prepared canal, it adapts better to the canal walls
(Fig. 19.35A)
Confirm the fit of cone radiographically, if found satis-
D E F
factory, remove it from the canal and place in sodium
hypochlorite
Irrigate the canal and then dry by rinsing it with alcohol
and latter using the paper points
Select the heat transferring instrument and pluggers
according to canal shape and size (Figs. 19.35B to D)
Pluggers are prefitted at 5 mm intervals so as to capture
maximum cross-section area of the softened gutta-percha
Lightly coat the canal with sealer
Cut the coronal end of selected gutta-percha at incisal or
occlusal reference point
Now use heated plugger to force the gutta-percha into the
canal. Blunt end of plugger creates a deep depression in
the center of master cone (Fig. 19.35E). The outer walls
of softened gutta-percha are then folded inward to fill the
central void; at the same time, mass of softened gutta-
percha is moved apically and laterally. This procedure
also removes 2–3 mm of coronal part of gutta-percha G H I
Once apical filling is done, complete obturation by doing Figs. 19.35A to H (A) Select the master gutta-percha cone; (B) select
backfilling. Obturate the remaining canal by heating the plugger according to canal shape and size; (C) Larger sized
small segments of gutta-percha, carrying them into the plugger may bind the canal and may split the root; (D) Small plugger
canal and then compacting them using heated pluggers is ineffective for compaction; (E) Heated plugger used to compact
as described above (Figs. 19.35F to H) gutta-percha; (F to H) Back filling of the canal.
Take care not to overheat the gutta-percha because it will Canal shape should be continuous perfectly tapered
become too soft to handle Do not set the System B at high temperature because this
Do not apply sealer on the softened segments of gutta- may burn gutta-percha
percha because sealer will prevent their adherence to the While down packing, apply a constant firm pressure
body of gutta-percha present in the canal
After completion of obturation, clean the pulp cham- Technique (Figs. 19.37A to G)
ber with alcohol to remove remnants of sealer or Select the Buchanan plugger which matches with the
gutta-percha
selected gutta-percha cone. Place rubber stop on the
plugger and adjust it to its binding point in the canal
Advantages 5–7 mm short of working length
• Excellent sealing of canal apically, laterally and obturation of Confirm the fit of the gutta-percha cone
lateral as well as accessory canals
• Oval canals get better filled than with lateral compaction
Dry the canal, cut the gutta-percha 0.5 mm short of work-
technique ing length, and apply sealer in the canal
With the System B turned on to “use,” place it in touch
Disadvantages
• Increased risk of vertical root fracture mode, set the temperature at 200°C, and dial the power
• Overfilling of canals with gutta-percha or sealer from apex setting to 10. Sever the cone at the orifice with preheated
• Time-consuming plugger. Afterwards plugger is used to compact the
• Difficult to use in curved canals where rigid pluggers are softened gutta-percha at the orifice. Push the plugger
unable to penetrate to required depth smoothly through gutta-percha to 3–4 mm of binding
point
Release the switch. Hold the plugger here for 10 s with a
Temperature Control sustained pressure to take up any shrinkage which might
occur upon cooling of gutta-percha
System B, Downpak cordless obturation device, and Maintaining the apical pressure, activate the heat switch
Touch and heat are the devices which permit temperature
for 1 sec followed by 1 sec pause and then remove the
control.
plugger
After removal of plugger, introduce a small flexible end
System B: Continuous Wave of another plugger with pressure to confirm that apical
Condensation Technique mass of gutta-percha has cooled, set and not dislodged.
System B is newly developed device by Buchanan for warm- Following radiographic confirmation, canal is ready for
ing gutta-percha in the canal. It monitors temperature at the the backfill by any means
tip of heat carrier pluggers, thereby delivering a precised Advantages
amount of heat (Fig. 19.36). It creates single wave of heating and compacting thereby.
To have satisfactory 3-D obturation by using System B Compaction of filling material can be done at the same
technique, following precautions should be taken: time when it has been heat softened
Excellent apical control
Less technique sensitive
Fast, easy, predictable
Thorough condensation of the main canal and lateral
canals
Compaction of obturating materials occurs at all levels
simultaneously throughout the momentum of heating
and compacting instrument apically
Lateral/Vertical Compaction of
Warm Gutta-Percha
Vertical compaction causes dense obturation of the root
canal, while lateral compaction provides length control and
satisfactory ease and speed.
Fig. 19.36 System B cordless endodontic obturation system. Advantages of both of these techniques are provided
Courtesy: Kerr Sybron Endo. by a newer device, Endotec II, which helps the operator to
A B
Fig. 19.38 Obturation using Endotec II device.
employ length control with warm gutta-percha technique.

It comes with battery which provides energy to heat the
attached plugger and spreader (Fig. 19.38).
Technique
Adapt master gutta-percha cone in canal, select endotec
plugger, and activate the device
Insert the heated plugger in canal beside master cone to
be within 3–4 mm of the apex using light apical pressure
Afterwards, unheated spreader can be placed in the canal
C D
to create more space for accessory cones. This process is
continued until canal is filled
Advantages
Three-dimensional obturation of canal
Better sealing of accessory and lateral canals
Endotec can also be used to soften and remove the
gutta-percha
Calamus
Calamus is a recent technique of obturation of root canal
system. It combines both Calamus “Pack” and Calamus
“Flow” handpiece (Fig. 19.39). With the Pack and Flow posi-
tioned side by side, a dense apical plug is created. Its hand-
piece has a 360° activation cuff, which provides a smooth,
continuous flow of gutta-percha. Calamus Flow handpiece
is used with a one-piece gutta-percha cartridge and inte-
E F G grated cannula to dispense warm gutta-percha. Calamus
Figs. 19.37A to G (A) Selection of plugger according to shape Pack handpiece with an electric heat plugger (EHP) is used
and size of the canal; (B) Confirm fit of the cone; (C) Filling the to thermosoften, remove and condense gutta-percha. The
canal by turning on System B; (D) compaction of gutta-percha EHPs are available in three ISO color—black, yellow, and
by keeping the plugger for 10 s with sustained pressure; (E and blue—which correspond to working end diameters and
F) Removal of plugger; (G) Apical filling of root canal completed. tapers of 40/03, 50/05, and 60/06, respectively.
Fig. 19.39 Calamus dual obturation system. Fig. 19.40 Thermomechanical compaction of gutta-percha,
McSpadden compaction.
Sectional Method of Obturation/ McSpadden Compaction/

Chicago Technique Thermomechanical Compaction
In this technique, small pieces of gutta-percha cones are of the Gutta-Percha
used to fill the sections of the canal. It is also known as McSpadden introduced a technique in which heat was
Chicago technique because it was widely promoted by used to decrease the viscosity of gutta-percha and thereby
Coolidge, Lundquist, Blayney, all from Chicago. increasing its plasticity (Fig. 19.40). This technique
involves the use of a compacting instrument (McSpadden
Technique compacter) which resembles inverted Hedstroem file.
This is fitted into latch-type handpiece and rotated at
A gutta-percha cone of same size of the prepared root 8,000–10,000 rpm alongside gutta-percha cones inside the
canal is selected and cut into sections of 3–4 mm long canal walls (see Fig. 19.39). At this speed, heat produced
Select a plugger which loosely fits within 3 mm of by friction softens the gutta-percha and designs of blade
working length forces the material apically.
Apply sealer in the canal Because of its design, the blades of compaction break eas-
One end of gutta-percha is mounted to heated plugger ily if it binds, so it should be used only in straight canals. But
and is then carried into the canal and apical pressure is nowadays, its newer modification in the form of microseal
given. After this, disengage the plugger from gutta-percha condenser has come, which is made up of nickel–titanium.
by rotating it Because of its flexibility, it can be used in curved canals.
Radiograph is taken to confirm its fit. If found satisfac-
tory, fill the remainder of the canal in the same manner Advantages
Requires less chair-side time
Advantages Ease of selection and insertion of gutta-percha

It seals the canals apically and laterally Dense, 3-D obturation
In case of post and core cases, only apical section of
canal is filled Disadvantages
Liability to use in narrow and curved canals (canal has
Disadvantages to be enlarged to a size no. 45)
Time-consuming Frequent breakage of compactor blades
If canal gets overfilled, difficult to remove sections of Overfilling of canals
gutta-percha Shrinkage of gutta-percha on cooling
Thermoplasticized Injectable
Gutta-Percha Obturation
Obtura II Heated Gutta-Percha System/
High-Heat System
This technique was introduced in 1977 at Harvard insti-
tute. It consists of an electric control unit with pistol grip
syringe and specially designed gutta-percha pellets which
are heated to approximately 365–390°F (185–200°C) for
obturation (Fig. 19.41). In this, regular β-phase of gutta-
percha is used.
Prerequisites for Canal to be filled by Obtura II

Continuous tapering funnel shape for unrestricted flow A B C
of softened gutta-percha (Fig. 19.42A) Figs. 19.42A to C (A) Tapering funnel shape of prepared canal is
A definite apical stop to prevent overfilling well suited for obturation using obtura II; (B) Needle tip of obtura II
should reach 3–5 mm of apical end; (C) Compaction of gutta-percha
Indications for using Obtura II using plugger
Roots with straight or slightly curved canals

For backfilling of canals Now use pluggers to compact the gutta-percha; pluggers
For obturation of roots with internal resorption, perfora-
are dipped in isopropyl alcohol or sealer to prevent stick-
tions, etc.
ing of the gutta-percha
Continuous compaction force should be applied
Technique throughout the obturation of whole canal to compensate
Before starting the obturation, applicator needle and shrinkage and to close any voids if formed.
pluggers are selected. Needle tip should reach ideally
3–5 mm of the apical terminus passively (Fig. 19.42B)
Apply sealer along the dentinal walls to fill the interface Variations in Thermoplasticizing Technique
between gutta-percha and dentinal walls of Gutta-Percha
Place obtura needle loosely 3–5 mm short of apex,
as warm gutta-percha flows and fills the canal, back
Ultrasonic Plasticizing of Gutta-Percha
pressure pushes the needle out of the canal (Fig. It has been seen that ultrasonics can be used to fill the
19.42C) canals by plasticizing the gutta-percha
Earlier, cavitron US scaler was used for this purpose but
its design limited its use only in anterior teeth
Recently, ENAC ultrasonic unit comes with an attached
spreader which has shown to produce homogenous
compaction of gutta-percha
Ultrafil System
This system uses low temperature, (90°C) plasticized
α-phase gutta-percha
Here gutta-percha is available in three different viscosi-
ties for use in different situations
Regular set and the firm set with highest flow properties
primarily used for injection and need not be compacted
Fig. 19.41 Obtura II manually. Endoset is more of viscous and can be con-
Courtesy: Obtura Spartan, Fenton. densed immediately after injection
Fig. 19.44 Thermafil cones.
Fig. 19.43 Needle should reach 6–7 mm from the apical end.
Technique
Cannula needle is checked in canal for fitting. It should be
6–7 mm from apex (Fig. 19.43). After confirming the fit, it
is placed in heater which has a preset temperature of 90°C.
Apply sealer in the canal and passively insert the needle
into the canal. As the warm gutta-percha fills the canal,
its backpressure pushes the needle out of the canal
Once needle is removed, prefitted plugger dipped in
alcohol is used for manual compaction of gutta-percha
Difference between Obtura II and Ultrafil II

Obtura II Ultrafil II
Fig. 19.45 The carrier is not primary cone for obturation. It acts as
• Uses high temperature • Uses low temperature a carrier for carrying thermoplasticized gutta-percha.
• Uses gun with heating • There is no heating
element element
• Uses needles of 18, 20, 22, • Uses needles of 22 gauze
and 25 gauze
• Digital display of • No digital read out
temperature
• Working time is 3–10 min • Working time is <1 min
Solid Core Carrier Technique

Thermafil Endodontic Obturators Fig. 19.46 Therma cut bur.
Thermafil endodontic obturators are specially designed
of flexible steel, titanium, or plastic carriers coated with
α-phase gutta-percha. Thermafil obturation was devised plastic crystal or polysulfone polymer. The carrier is not the
by W. Ben Johnson in 1978. primary cone for obturation. It acts as carrier and condenser
In this, carriers are made up of stainless steel, titanium, for thermally plasticized gutta-percha (Fig. 19.45). Plastic
or plastic. They have ISO standard dimension with matching cores allow postspace to be made easily and they can be
color coding in the sizes of 20–140 (Fig. 19.44). Plastic car- cut off by heated instrument, stainless steel bur, diamond
rier is made up of special synthetic resin which can be liquid stone, or therma cut bur (Fig. 19.46).
Technique (Figs. 19.47A to E) Advantages

Requires less chair-side time
Select a thermafil obturator of the size and shape which Provides dense 3-D obturation as gutta-percha flows
fits passively at the working length (Fig. 19.47A). Verify into canal irregularities such as fins, anastomoses, and
the length of verifier by taking a radiograph lateral canals
Now disinfect the obturator in 5.25% sodium hypochlo- No need to precurve obturators because of flexible
rite for 1 min and then rinse it in 70% alcohol carriers
Preheat the obturator in “Thermaprep” oven for some- Since this technique requires minimum compaction, so
time (Fig. 19.47B). This oven is recommended for heating less strain while obturation with this technique
obturator because it offers a stable heat source with more
control and uniformity for plasticizing the gutta-percha
Dry the canal and lightly coat it with sealer. Place the Ultrafil 3-D
heated obturator into the canal with a firm apical pres- Ultrafil 3-D is injectable gutta-percha system which provides
sure (Fig. 19.47C) to the marked working length three viscosities to accommodate different techniques.
Working time is 8–10 s after removal of obturator from Success-Fil (Coltene/Whaledent, Inc.) utilizes high viscos-
oven. If more obturators are required, insert them ity gutta-percha which comes in a syringe. Sealer is lightly
immediately coated on the canal walls and the carrier with gutta-percha
Verify the fit of obturation in radiograph. When found is placed in the canal to the prepared length. Gutta-percha
accurate, while stabilizing the carrier with index finger, is then compacted around the carrier with various pluggers
sever the shaft level with the orifice using a prepi bur or an depending on the canal morphology. Then carrier is severed
inverted cone bur in high-speed handpiece (Fig. 19.47D) at the orifice with a bur.
Do not use flame heated instrument to sever the plastic
shaft because instrument cools too rapidly and thus
may cause inadvertent obturator displacement from Cold Gutta-Percha Compaction Technique
the canal Gutta Flow
Now use a small condenser coated with vaseline or
dipped in alcohol, to condense gutta-percha vertically Gutta flow is eugenol-free radiopaque form which can
around the shaft (Fig. 19.47E) be injected into root canals using an injectable system
When post is indicated, sever the obturator with the fissure (Fig. 19.48). It is self-polymerizing filling system in which
bur at the selected length and give counterclockwise rota- gutta-percha in powder form is combined with a resin sealer
tion of shaft following insertion to disengage the instrument in one capsule.
A B C D E
Figs. 19.47A to E (A) Select a thermafil obturator which fits into the canal passively at the working length; (B) Preheat the thermaprep
oven; (C) Place the heated obturator into the canal with firm apical pressure; (D) Cut the thermafil using therma cut bur; (E) Condense
gutta-percha vertically around the shaft.
Contraindications
Teeth with open apex
Large ovoid-shaped canals, like maxillary incisors,
premolars with oval single canals, etc.
Steps
Select a silver cone conforming the final shape and size
of the prepared canal. Check if it fits radiographically. If
Fig. 19.48 Gutta Flow. found satisfactory, remove it from the canal and sterilize
it over an alcohol flame
Dry the canal and coat the canal walls with sealer
Composition: Gutta flow consists of polydimethylsiloxane Insert the cone into the canal with sterile cotton plier or
matrix filled with powdered gutta-percha, silicon oil, Stieglitz forceps
paraffin oil, platinum, zirconium dioxide, and nano silver. Take a radiograph to see the fit of cone. If satisfactory,
Advantages fill the remaining canal with accessory gutta-percha
Easy to use cones
Time saving
Remove excess of sealer with cotton pellet and place
Does not require compaction restoration in the pulp chamber
Does not require heating Advantages
Biocompatible Easy handling and placement
Can be easily removed for retreatment Negotiates extremely curved canals
Radiopaque in nature
Obturation with Silver Cone Mild antibacterial property
Use of silver cones is not the preferred method of obtura- Disadvantages

tion, mainly because of corrosion. Their use is restricted to Prone to corrosion resulting in loss of apical seal
teeth with fine, tortuous, curved canals which make use of Difficult to retrieve if it is snugly fitting
gutta-percha with difficulty (Fig. 19.49). Nonadaptable, so does not seal accessory canals
Indications for use of silver cones

In round and straight canals, like canals of maxillary pre- Stainless Steel
molars, mesial canals of mandibular molars, and buccal They are more rigid than silver points and are used for fine
canals of maxillary molars and tortuous canals. They cannot seal the root canals com-
In mature teeth with small calcified canals
pletely without use of sealer.
Apical Third Filling

Sometimes apical barriers are needed to provide apical
stop in cases of teeth with incomplete root development,
overinstrumentation, and apical root resorption. Various
materials can be used for this purpose. They are designed
to allow the obturation without apical extrusion of the
material in such cases.
Apical third filling

• Carrier-based system
– Simplifill obturator
– Fiberfill obturator
• Paste system
– Dentin chip filling
– Calcium hydroxide filling
Fig. 19.49 Cross-section of canal obturated with silver cone – MTA filling
showing poor adaptation of the cone in irregularly shaped canal.
Simplifill Obturator Set the rubber stop 4 mm short of the working length and
advance GP plug apically without rotating the handle
It was originally developed at light speed technology so Once GP plug fits apically, rotate the carrier anticlock-
as to complement the canal shape formed by using light wise without pushing or pulling the handle of carrier
speed instruments. In this, the apical gutta-percha size is Now backfilling of canal is done using syringe system
the same ISO size as the light speed master apical rotary.
Here a stainless steel carrier is used to place gutta-percha
in apical portion of the canal (Fig. 19.50).
Fiberfill Obturator
This obturation technique combines a resin post and
Steps (Figs. 19.51A to D) obturator forming a single until and apical 5–7 mm of
Try the size of apical GP plug so as to ensure an optimal gutta-percha
apical fitting. This apical GP plug is of same size as the
This apical gutta-percha is attached with a thin flexible
light speed master apical rotary filament to be used in moderately curved canals
Advantage of this technique is that due to presence of
dual cure resin sealer, chances of coronal microleakage
are less
But it poses difficulty in retreatment cases
Dentin Chip Filling

Dentin chip filling forms a Biologic seal. In this technique,
after thorough cleaning and shaping of canal, H-file is
used to produce dentin powder in central portion of the
canal, which is then packed apically with butt end of
paper point.
Technique (Figs. 19.52A to D)

Clean and shape the canal
Fig. 19.50 Simplifill stainless steel carrier with Produce dentin powder using hedstroem file or Gates-
apical gutta-percha plug. Glidden drill
A B C D
Figs. 19.51A to D (A) Check the fit of apical gutta-percha (GP) plug; (B) condense apical GP plug to working length; (C) Once GP plug fits
apically, rotate the carrier anticlockwise without pushing or pulling the handle of carrier; (D) Backfilling of canal is done using syringe system.
A B C D
Figs. 19.52A to D (A) Compaction of dentin chips apically; (B) dentin chips produced by use of Gates-Glidden drills; (C) chips being
compacted with blunt end of instrument/paper point; (D) compaction of dentin chips in apical 2 mm from working length to stimulate
hard tissue formation.
Using butt end of a paper point, push and compact dentin

chips apically
1–2 mm of chips should block the apical foramen. The
density of pack is checked by resistance to perforation
by #15 or 20 file
Backpacking is done using gutta-percha compacted
against the plug
Advantages
Biocompatible
Promotes healing and decreases inflammation
Prevents extrusion of filling material from the canal
space
Disadvantage
Care must be taken in this technique, because infected pulp
Fig. 19.53 Placement of Ca(OH)2 in the canal.
tissue can be present in the dentinal mass.
Calcium Hydroxide
Mineral Trioxide Aggregate
It has also been used frequently as apical barrier. Calcium
hydroxide has shown to stimulate cementogenesis. It can Mineral trioxide aggregate was developed by Dr Torabinejad
be used both in dry or moist state. in 1993 (Fig. 19.54). It contains tricalcium silicate, dical-
Moist calcium hydroxide is placed with the help of plug- cium silicate, tricalcium aluminate, bismuth oxide, calcium
ger and amalgam carrier, injectable syringes, or by lentulo sulfate, and tetracalcium aluminoferrite.
spirals. pH of MTA is 12.5, thus having its biological and histo-
Dry form of Ca(OH)2 is carried into canal by amalgam logical properties similar to calcium hydroxide. Setting time
carrier which is then packed with pluggers (Fig. 19.53). is 2 h and 45 min. In contrast to Ca(OH)2, it produces hard
Calcium hydroxide has shown to be a biocompatible mate- setting nonresorbable surface.
rial with potential to induce an apical barrier in apexifica- Because of being hydrophilic in nature, it sets in a moist
tion procedures. environment. It has low solubility and shows resistance to
Coronal Seal
Irrespective of the technique used to obturate the canal,
coronal leakage can occur through well-obturated canals,
resulting in infection of the periapical area. Coronal seal
should be enhanced by the application of restorative
materials (like Cavit, super EBA cement, MTA) over the
canal orifice.
Postobturation Instructions
Postoburation pain can be seen in some cases. Since
pain is a subjective symptom which is related to many
factors like presence of preoperative pain, periradicular
infection, retreatment, etc. Sometimes, pain is due to
extrusion of root canal filling or a tiny bubble of air, which
Fig. 19.54 Mineral trioxide aggregate.
can be forced out periapically causing pressure and pain.
Pain is most likely to occur in first 24 h and decreases as
the time passes. Patient is advised not to chew unduly
on the treated tooth until it is protected by permanent
restoration.
Patient Recall
Patient should be recalled regularly to evaluate tissue repair
and healing progresses.
In case of periapical radiolucency, radiographs should be
taken at 3, 6, and 9 months interval period to see continued
new bone formation. Radiograph of a successful endodontic
treatment shows uniformly thickened periodontal ligament
and continuous lamina dura along the root.
Repair Following Endodontic

Fig. 19.55 Due to loose, granular nature of MTA, a special carrier Treatment
like messing gun or amalgam carrier is used for carrying it. Repair of tooth being treated begins as soon as infection is
controlled.
marginal leakage. It also exhibits excellent biocompatibility Repair occurs in the following steps:
in relation with vital tissues. • Organization of blood clot
To use MTA, mix a small amount of liquid and powder • Formation of granulation tissue
to putty consistency. Since MTA mix is a loose granular • Development of scar tissue by laying down of collagen fibers
aggregate, it cannot be carried out in cavity with normal
cement carrier and thus has to be carried in the canal with In periapical area, bone is there. Here healing process is
messing gun, amalgam carrier, or specially designed car- more complicated because soft tissue must be converted
rier (Fig. 19.55). After its placement, it is compacted with to hard tissue
micropluggers. Bone contains protein matrix filled with calcium com-
Advantages of MTA include its excellent biocompat- pounds like calcium phosphate and calcium carbonate.
ibility, least toxicity of all the filling materials, radiopaque This protein matrix is formed by osteoblasts
nature, bacteriostatic nature, and resistance to marginal Osteoblasts produce enzyme called alkaline phosphatase,
leakage. However, it is difficult to manipulate with long which separates in organic phosphorus from organically
setting time (3–4 h). bound phosphorus
This increase of phosphate ions forms saturated solution Bibliography
of calcium phosphate, which precipitates into matrix.
The precipitated areas of calcium phosphate join to form 1. Bailey GC, NgYL, Cunnington SA, et al. Part II: an in vitro
spongy trabeculae investigation if the quality of obturation. Int Endod J
Resorption and deposition of bone may occur simul- 2004;37:694–8.
taneously depending upon degree of periapical dam- 2. Bowman CJ, Baumgartner JC. Gutta-percha obturation of
age; repair usually takes 6–12 months after endodontic lateral grooves and depression. J Endod 2002;28:220–3.
treatment 3. Buchanan LS. Filling root canal system with centered con-
Since repair proceeds from periphery to center, the densation: concepts, instruments and techniques. Endod
granulation tissue formation, fibrous connective tissue Prac 2005;8:9–15.
4. Cobankara FK, Orucoglu H, Sengun A, Belli S. The quantita-
maturation, and finally matrix for bone formation occur
tive evaluation of apical sealing of four endodontic sealers
in steps
J Endod. 2006;32(1):66-8.
In some cases, connective tissue matures into dense 5. Eldeniz AU, Mustafa K, Orstavik D, Dahl JE. Cytotoxicity of
fibrous tissue instead of bone. These areas represent as new resin-, calcium hydroxide– and silicone-based root canal
areas of rarefactions in radiographs, though histologically sealers on fibroblasts derived from human gingiva and L929
healing has taken place cell lies. Int Endod J 2007;40:329–37.
6. Friedman CE, Sandrik JL, Heuer MA, Rapp GW. Composition
and physical properties of gutta-percha endodontic filling
Questions materials. J Endod 1977;3:304–8.
7. Grossman L. Endodontics. 11th ed. Philadelphia, PA: Lea &
1. What are the different materials used for obturation? Febiger; 1988
2. Write in detail about gutta-percha with its advantages 8. Grossman LI. Endodontic practice. Philadelphia, PA: Lea and
and disadvantages? Febiger, 1978.
9. Gutmann J, Witherspoon D. Chapter 9: obturation of the
3. What are the functions of root canal sealers? Classify
cleaned and shaped root canal system. Pathways of the pulp.
different root canal sealers?
7th edition St Louis, MO: Cohen and Burns; 2002.pp. 293–364.
4. How would you know that root canal is ready for 10. Gutmann JL, Rakusin H. Perspectives on root canal obturation
obturation? with thermoplasticized injectable gutta-percha. Int Endod J
5. Classify different obturation techniques. Explain in 1987;20:261–70.
detail about lateral compaction technique? 11. Juhasz A, Verdes E, Tokes L, Kobor A, Dobo-Nagy C. The influ-
6. What are the advantages and disadvantages of vertical ence of root canal shape on the sealing ability of two root canal
compaction technique? sealers. Int Endod J 2006;39:282–6.
7. Describe biological considerations for selecting a filling 12. Kytridou V, Gutmann JL, Nunn MH. Adaptation and sealability
material. of two contemporary obturation techniques in the absence of
8. What are different endodontic obturation techniques? the dentinal smear layer. Int Endod J 1999;32:464–74.
13. Lacey S, Pitt Ford TR, Yuan XF, Sherrif M, Watson T. The effect
Describe in detail lateral compaction technique.
if temperature on viscosity of root canal sealers. Int Endod J
9. Why is it necessary to hermetically seal the root
2006;39:860–33.
canal? Describe root canal sealers and obturating 14. ldeniz AU, Ørstavik D. Physical properties of newly developed
materials. root canal sealers. Int Endod J 2005;38:935.
10. Describe prerequisite of root canal obturation and its 15. Lohbauer U, Gambarini G, Ebert J, Dasch W, Petschelt A.
various techniques. Calcium release and pH-characteristics of calcium hydroxide
11. Enumerate different methods of root canal obturation plus points. Int Endod J 2005;38:683–9.
and describe in detail about vertical condensation 16. Mayer B, Roggendorf MJ, Ebert J, Petschelt A, Frankenberger
technique highlighting merits and demerits? R. Influence of sealer placement on apical extrusion of two
12. What are the ideal requirements of root canal filling root canal sealers. Int Endod J 2005;38:928.
materials? Name various obturation techniques and 17. Patel DV, Sherriff M, Ford TR, Watson TF, Mannocci F. The
penetration of RealSeal primer and tubliseal into root canal
describe vertical condensation techniques.
dentinal tubules: a confocal microscopic study. Int Endod J
13. Write short notes on:
2007;40:67–71.
• System B obturation system 18. Santos MD, Walker III WA, Carnes Jr. DL. Evaluation of apical
• Sectional method of obturation seal in straight canals after obturation using the Lightspeed
• Obtura II sectional method. J Endod 1999;25:609–12.
• Thermafil endodontic obturation 19. Schilder H, Goodman A, Aldrich W. The thermomechanical
• Timing of obturation properties of gutta-percha. V. Volume changes in bulk gutta-
• Gutta-percha. percha as a function of temperature and its relationship to
molecular phase transformation. Oral Surg Oral Med Oral 22. Tunga U, Bodrumlu E. Assessment of the sealing ability of a
Pathol 1985;59:285–96. new root canal obturation material. J Endod 2006;32:876–8.
20. Schilder H. Filling root canals in three dimensions. Dent Clin associated with thermoplastic gutta percha. J Endod
North Am 1967;11:723–44. 2001;27:512–15.
21. Silver GK, Love RM, Purton DG. Comparison of two vertical 23. Wollard RR, Brough SO, Maggio J, Seltzer S. Scanning electron
condensation obturation techniques: touch ‘n’ heat modified microscopic examination of root canal filling materials. J
and system B. Int Endod J 1999;32:287–95. Endod 1976;2:98–110.

Endo

Uploaded by

Copyright:

Available Formats

Endo

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Endo

Uploaded by

Copyright:

Available Formats

7

Examination and Diagnosis

Electric pulp testing used to determine pulp vitality.

Nonsurgical cassette used for endodontic treatment.

Hand pluggers in different sizes.

required goals. As a result, numerous irrigants are used in mod-

for each irrigant on a case-by-case basis. Depending on the status

*Flex R *K–Flex (small) *K–Flex (large) Hedstrom * Unifile

condensation (compaction) of the primary gutta-percha cone and

Irrigation syringes containing different irrigation solutions that

EndoActivator used for irrigation activation.

1. All of the following are normally included in an examination kit EXCEPT:

saline. After drainage, the clinician must decide whether to place a

Root End Surgery (Apicoectomy)

Surgical cassette for root end surgery.

Different types of blades, from top to bottom: (1) standard 15

categories of retro-filling materials have been used in endodontic

13. Khalighinejad N, Aminoshariae A, Kulild JC, et al.: The effect of

teeth were shown to exist. For example, in the casts of mandibular

Root Canal Anatomy Since the Age of

Root Canal Components and Morphology

1 apical foramen 2 apical foramina 3 apical foramina 4 apical foramina

1 1-2-1 1-2-1-2-1 4-1 2 2-3-2 1-2 3 1-3 4

1-2-3-1 1-2-3-2-1 1-3-1 2-3-2-3-2 1-2-1-2 2-3-4-3-2 1-2-3 1-2-1-3 3-4

2-1 2-1-2-1 2-3-1 1-2-3-2 3-1-2 2-1-2 1-2-3-2-3 2-1-3 5-4

3-1 3-2-1 3-2-1-3-1 3-2 2-1-2-1-2 4-2 2-3 3-2-3 1-2-3-4

Distal Mesial Distal Mesial

Root Root Root

Apical Canal Canal Curvature and Size

Root Canal Configuration Systems Taurodontism

DB RDL RDL RML

Different views of a three-dimensional (3D) micro–computed tomography (micro-CT) models of

Buccal View Distal view Lingual View

It is important to point out that mandibular molar teeth

from a discontinuation of the “C” outline.

Melton’s classification96 stated that categories II and III have

Maxillary Central Incisor Mandibular Central Incisor

Middle Third Middle Third

Apical Third Apical Third

Maxillary Lateral Incisor Mandibular Lateral Incisor

Middle Third Middle Third

Apical Third Apical Third

Three-dimensional (3D) micro–computed tomography (micro-CT) models and two-dimensional

Root canal configurations are classified according to Vertucci.40

Maxillary Canine Mandibular Canine

Middle Third Middle Third

Apical Third Apical Third

Three-dimensional (3D) micro–computed tomography (micro-CT) models and two-dimen-

B, Buccal root/canal; P, palatal root/canal.

Root canal configurations are classified according to Vertucci.40

Maxillary First Premolar Mandibular First Premolar

Middle Third Middle Third

Apical Third Apical Third

Maxillary Second Premolar Mandibular Second Premolar

Middle Third Middle Third

Apical Third Apical Third

Three-dimensional (3D) micro–computed tomography (micro-CT) models and two-dimensional

MB, Mesiobuccal root/canal; DB, distobuccal root/canal; P, palatal root/canal.

M, Mesial root/canal; D, distal root/canal.

Maxillary First Molar Mandibular First Molar

Flex R K–Flex (small) K–Flex (large) Hedstrom Unifile