Intensive Phase

ENDODONTICS

Prepared by:
Dr. NICA JEORGIA P. SALAZAR
Outline
I. Pulp X. Procedural Errors
II. Morphology of the Root Canal XI. Endodontic Surgery
System XII. Dentoalveolar Injuries
III. Diagnostic Testing XIII.Endodontic Periodontal Lesions
IV. Pulp pathologies XIV.Tooth Bleaching
V. Periapical Pathologies XV. Restoration of Endodontically
VI. Pulp Therapy Procedures Treated Tooth
VII. Root Canal Treatment
VIII. Irrigants
IX. Root Canal Medicaments
Pulp
1. Odontoblastic zone
2. Cell-free zone of Weil- capillaries & nerves
(plexus of Raschkow)
3. Cell-rich zone- fibroblasts, macrophages,
dendritic cells, undifferentiated mesenchymal
cells
4. Pulp proper- contains larger blood vessels &
nerves which branch out to supply the outer
layers of the pulp, fibroblasts, macrophages,
dendritic cells, lymphocytes, mast cells

Fibers: Type I collagen; elastic fibers

Nerves: Nociceptive Only
 A DELTA FIBERS C FIBERS
Location Cell-free zone Pulp proper
Threshold Lower Higher
Size Larger Smaller
Myelination Myelinated Unmyelinated
Pain Quality Sharp, stabbing, Dull, throbbing,
sudden pain lingering pain
First nerve fibers to Irreversible pulp
react to initial/ damage
reversible pulp
injury
Pulp Changes with Aging

Decrease Increase
Size of Pulp chamber Collagen fibers
Number of cells, blood vessels, nerves Pulp stones
Canal calcifications
Morphology of the Root Canal System
Pulp chamber
 # of roots = # of orifices = # of canals

EXCEPT:
1. Mx 1st molar- 4 or 3
2. Md 1st molar- 3 or 4
3. Md lateral incisor- Most common anterior tooth with 2 orifices and 2
canals

*Mx 2nd molar- 3 or 4 (watch out for the MB2)

*Md 2nd molar- 3 or 4 or c-shaped
Root canals
MAXILLARY MAIN # CANAL VARIATION MANDIBULAR MAIN # CANAL VARIATION
1 1 (100%) 1 1 (70%) 2
2 1 2 2 1 2
3 1 (95%) 2 3 1 (70-89%) 2
4 2 (85%) 1 4 1 (70-75%) 2
5 2 (50%) 1 (50%) 5 1 (85%) 2
6 4 (60%) 3 6 3 (Asians) 4 (Caucasians)
7 3 4 7 3 2
 Root Apex
Apical foramen= Major Apical Diameter

Apical Constriction= Minor Apical Diameter

= DCJ
=junction of pulp & PDL
0.5mm
= point at which canal instrumentation
0.5mm
& obturation should stop
Outline
I. Pulp X. Procedural Errors
II. Morphology of the Root Canal XI. Endodontic Surgery
System XII. Dentoalveolar Injuries
III. Diagnostic Testing XIII.Endodontic Periodontal Lesions
IV. Pulpal pathologies XIV.Tooth Bleaching
V. Periapical Pathologies XV. Restoration of Endodontically
VI. Pulp Therapy Procedures Treated Tooth
VII. Root Canal Treatment
VIII. Irrigants
IX. Root Canal Medicaments
Vitality Test
1. Thermal test= suggests whether pulp is reversibly inflamed,
irreversibly inflamed or necrotic in nature
• Vital: (+), note the severity and duration of pain/ discomfort
• Nonvital: (-), no response
• Cold Test= Dichlorodifluoromethane (endo ice, -26.2 deg C), Ethyl
chloride (-5deg C), ice sticks, cold water bath
• Heat Test= Heated GP, hot water bath
2. Electric Pulp Test-suggests whether pulp is vital or non-vital
-detects presence of viable nerve fibers
• Conducting medium: toothpaste
• Contraindication: patients with cardiac pacemaker
EPT- presence of viable nerves
FALSE NEGATIVE FALSE POSITIVE
Multiple canals with partial necrosis Liquefactive necrosis
Probe contacting a large restoration Probe contacting a metallic restoration
Recently traumatized tooth Nervous patient
Immature tooth with open apices Patient in severe pain
Obliterated pulp chamber or calcified canal Poor tooth isolation
Anesthetized tooth
Patients who have recently taken analgesics
No conductive medium placed
Periodontal Examination
3. Percussion- presence of inflammation in the periapical area
• Pain is localized due to the presence of proprioceptive nerve fibers in
the PDL
• (+) = physical trauma, occlusal prematurity, periodontal disease,
extension of pulpal disease into PDL space

4. Palpation- helps characterize intraoral swelling

• (+)= pulp disease has communicated with adjacent soft tissue
5. Probing and mobility- detects amount of periodontal ligament and
bone destruction
-useful in traumatic cases
- Aids in differentiating pulpal from periodontal disease
Narrow Deep Pocket Endodontic in nature/ Mobility Grade Amount of mobility
-sinus Vertical fracture
-blowout 1 <1mm
-“precipitously” drops
2 >1mm
Broad-based pocket Periodontal in nature 3 Can be depressed
-conical vertically
Special Tests
6. Bite test- toothslooth
• Pain upon biting= inflammation of periapical tissues
• Pain upon release= Cracked Tooth Syndrome

7. Transillumination- fiberoptic light source

8. Anesthetic test- localizes which arch the diffused or referred pain is

coming from

9. Test cavity
10. Radiographic Exam
• Depth of carious lesion or previous restoration
• Number, location, shape, size, length, direction of roots and root
canals
 Abrupt change in canal appearance indicates splitting canals
SLOB rule
• Root fractures
• Periapical lesions
SLOB RULE
Etiology of Pulp Diseases
• Dental caries
• Trauma
• Operative procedures
• Apical extension of periodontal disease
• Hematogenous anachoresis
 Reversible Pulpitis Acute Irreversible Pulpitis Chronic Irreversible Necrotic
Pulpitis

Chief “Nangingilo ang ngipin ko” “Hindi ako makatulog sa “May butas ang “Maitim ang ngipin
Complaint gabi sa sakit ng ngipin ko” ngipin ko” ko”

HPI There is a mild to moderate, There is a severe continuous, Tooth was previously Patient noticed his
intermittent pain stimulated spontaneous pain intensified painful. anterior tooth
by thermal changes and/ or and prolonged by thermal darkened days after
changes. Pain usually lasts for
sweets. The pain usually lasts a he played in
more than 30 seconds,
few seconds, subsides upon intensified when lying down. basketball league.
removal of stimulus -diffused, referred, dull,
throbbing, sharp lancinating
pain
-after some time, pain
intensified by heat & relieved
by cold

MILD to MODERATE SEVERE

PROVOKED SPONTANEOUS
EASILY SUBSIDES PROLONGED
POSTURAL POSITION
REFERRED
 Reversible Pulpitis Acute Irreversible Chronic Irreversible Necrotic
Pulpitis Pulpitis
Clinical condition of Usually accompanied Tooth caries, Deep carious lesion, Grayish color
Tooth with deep carious extensive pulp polyp in open
lesion, large restorations, cavities, internal
restoration fractures exposing resorption (pink)
the pulp

Radiographic Exam - -/+ (no to minimal) -/+ (no to minimal) -/+ (no to minimal,
pronounced RL)
Histologic Hyperemia= inc. Exudation Large area of Partial or total
Appearance tissue exudate in continues so liquefaction suppurative
the pulp= inc. formation of necrosis necrosis
intrapulpal microabscess
pressure= nerves
easily stimulated so
lower threshold
Chronic Irreversible Pulpitis
• Chronic hyperplastic pulpitis (pulp polyp) -reddish mass of reparative
pulp tissue extruding through a large cavity usually in molars of
children
- proliferating capillaries and granulation tissue

• Internal Resorption- from chronic irritation leading to irreversible

inflammation
- Asymptomatic
- Ovoid or irregular radiolucency within canal
 Reversible Pulpitis Acute Irreversible Chronic Irreversible Necrotic
Pulpitis Pulpitis
Clinical condition of Usually accompanied Tooth caries, Deep carious lesion, Grayish color
Tooth with deep carious extensive pulp polyp in open
lesion, large restorations, cavities, internal
restoration fractures exposing resorption (pink)
the pulp

Radiographic Exam - -/+ (no to minimal) -/+ (no to minimal) -/+ (no to minimal,
pronounced RL)
Histologic Hyperemia= inc. Exudation Large area of Partial or total
Appearance tissue exudate in continues so liquefaction suppurative
the pulp= inc. formation of necrosis necrosis
intrapulpal microabscess
pressure= nerves
easily stimulated so
lower threshold
 Hyperemia Exudation continues

Liquefactive necrosis
Inflammatory exudates in the pulp Extravascular pressure increases
tissue Chronic Irreversible pulpitis

Ischemic Blood vessel

Increase intrapulpal pressure
Necrotic Tissues Suppurative necrosis

Nerves can be easily stimulated Necrotic Pulp

Microabscess formation

Reversible pulpitis Acute irreversible pulpitis

 Reversible Pulpitis Acute Irreversible Chronic Necrotic
Irreversible
EPT + (low current) +++ (lower current) + (high current) -
Thermal test + (easily subsides) +++ (prolonged) + (prolonged) -
Percussion - +/- -/+ -/+
Palpation - - - -/+
Treatment Restoration RCT or Extract
 Symptomatic AP Asymptomatic Condensing Chronic Apical Acute Apical Abscess
AP Osteitis Abscess
Chief complaint “Masakit ang - - “May pimple po “May nana po ako sa
ngipin ko kapag ako sa gilagid” gilagid”
ngumunguya”
Pain symptom Significant pain None to mild Symptomatic or If pain is present, Rapid onset of pain,
on mastication asymptomatic due to occasional spontaneous moderate to
and pressure, closing of sinus severe discomfort, swelling
severe tract; metallic with pus, extreme
spontaneous taste in the mouth tenderness to biting; may
discomfort be associated with elevated
temp, lymphadenopathy,
malaise, leukocytosis
Pulp status -reversible Necrotic Necrotic or Necrotic pulp Necrotic pulp
pulpitis irreversibly
-irreversible inflamed pulp
pulpitis
-necrotic
Treatment RCT or RCT or exo RCT or exo RCT or exo IND, RCT or exo
management of
etiology
Phoenix abscess, also “recrudescent abscess”
- Acute exacerbation of a chronic periapical lesion such as a cyst or a
granuloma
- Associated with initiation of RCT in an asymptomatic tooth with CAP
- Percussion: (+++)
- Palpation: (+++)
- Radiographic finding: periapical radiolucency on a root canal-treated tooth

Apical scar
- Healing of periapical disease by repair rather than regeneration
-Bone is replaced with dense fibrous connective tissue
-Commonly seen in asymptomatic root canal-treated teeth
- Radiographic finding: periapical radiolucency
- Does not need treatment
Radiolucencies associated with vital tooth,
not requiring endodontic therapy:
• Cementoma
• Traumatic Bone Cyst
• Globulomaxillary cyst
• Lateral Periodontal cyst
• Nasopalatine Duct cyst
Outline
I. Pulp X. Procedural Errors
II. Morphology of the Root Canal XI. Endodontic Surgery
System XII. Dentoalveolar Injuries
III. Diagnostic Testing XIII.Endodontic Periodontal Lesions
IV. Pulp Pathologies XIV.Tooth Bleaching
V. Periapical Pathologies XV. Restoration of Endodontically
VI. Pulp Therapy Procedures Treated Tooth
VII. Root Canal Treatment
VIII. Irrigants
IX. Root Canal Medicaments
 Vital Pulp Therapy Nonvital pulp therapy
Indirect Pulp Capping Pulpectomy
Direct Pulp Capping Root Canal Treatment
Pulpotomy Apexification- to chemically induce closure of root
-Partial (Cvek) Pulpotomy apex of immature permanent tooth

GOAL: To preserve vital pulp tissue & promote GOAL: to preserve the tooth in function
apexogenesis in young permanent teeth
 Vital Pulp Therapy
Indirect Pulp Capping Direct Pulp capping Pulpotomy Partial (Cvek)
Pulpotomy
Indications deep carious lesion with pinpoint (<0.5mm) Usually performed on Traumatic or carious
imminent pulp exposure exposure due to deciduous molars w/ carious exposure of immature
mechanical or pulp exposure provided that: permanent teeth
traumatic injury -pulp is normal/ with (<2mm)
reversible pulpitis only
-root length at least 2/3 of
original length
-pulpal hemorrhage can be
controlled
Procedure Excavate infected dentin, Apply CaOH liner to Amputate coronal pulp, Remove 1-2mm of
leave affected dentin the pulp exposure control bleeding, medicate superficial pulp tissue
then place CaOH liner then restore w/ Formocresol/ MTA, seal and control bleeding,
w/ ZOE apply CaOH to
promote
apexogenesis, seal
and restore
 Vital Pulp Therapy
Indirect Pulp Capping Direct Pulp capping

Indications deep carious lesion with pinpoint (<0.5mm)

imminent pulp exposure exposure due to
mechanical or
traumatic injury

Procedure Excavate infected dentin, Apply CaOH liner to

leave affected dentin then the pulp exposure
place CaOH liner then restore

Enamel caries: Streptococcus mutans

Dentinal caries: Lactobacillus acidophilus
Root/ Senile Caries: Actinomycosis viscosus
Zones of Dentinal Caries

INFECTED DENTIN
TURBID DENTIN INFECTED DENTIN

TRANSPARENT DENTIN
SUBTRANSPARENT DENTIN AFFECTED DENTIN

NORMAL DENTIN NORMAL DENTIN

 INFECTED DENTIN AFFECTED DENTIN
Bacteria is present No bacteria
Collagen is irreversibly denatured Collagen is reversibly denatured
Not mineralizable and must be removed Remineralizable, and should be preserved
Zone 4 (turbid zone) & zone 5 (infected dentin) Zone 2 (Subtransparent dentin) and zone 3
(transparent dentin)
Yellow, soft, mushy, cheese/curd-like Black, hard. Leathery dentin
Zones of Enamel Caries
 Vital Pulp Therapy
Indirect Pulp Capping Direct Pulp capping

Indications deep carious lesion with pinpoint (<0.5mm)

imminent pulp exposure exposure due to
mechanical or
traumatic injury

Procedure Excavate infected dentin, Apply CaOH liner to

leave affected dentin then the pulp exposure
place CaOH liner then restore
 Vital Pulp Therapy
Pulpotomy Partial (Cvek)
Pulpotomy
Indications Usually performed on Traumatic or carious
deciduous molars w/ carious exposure of immature
pulp exposure provided that: permanent teeth
-pulp is normal/ with (<2mm)
reversible pulpitis only
-root length at least 2/3 of
original length
-pulpal hemorrhage can be
controlled
Procedure Amputate coronal pulp, Remove 1-2mm of
control bleeding, medicate superficial pulp tissue
w/ Formocresol/ MTA, seal and control bleeding,
w/ ZOE apply CaOH to
promote
apexogenesis, seal
and restore
 Non-vital Pulp Therapy
Apexification Pulpectomy Root Canal Treatment
Goal To induce root apex closure by Complete removal of irreversibly Retain mature permanent tooth
hard tissue deposition inflamed/ necrotic pulp tissue to with fully developed root and
retain the tooth in function apex

Indications Immature Permanent teeth -Canals accessible -irreversible pulpitis

prior to RCT -Roots at least 2/3 original length -pulpal necrosis with or without
periapical disease
-intentional RCT
Procedure File and irrigate, CaOH / MTA File and irrigate, fill with
placed to promote hard tissue resorbable ZOE paste
deposition
Root Canal Treatment
1. Access Preparation
2. Chemomechanical Instrumentation
3. Obturation with core filling material and sealer
4. Final Restoration
Contraindications to RCT:
• Non-restorable tooth
• Vertical Root Fracture
Most common iatrogenic: grossly enlarged canal, excessive condensation
forces during obturation, non-strategic post placement
May be due to trauma
• Insufficient Periodontal Support
• Massive Internal/ External Resorption
• Tooth unsuitable for instrumentation
Root Canal Treatment
1. ACCESS PREPARATION- provide straight line access to the apical
portion of the canal (up to apical foramen or to curvature of canal)
Caries removal
Unroof Pulp Chamber
Straight Line Access
Pulp Tissue Removal
Conserve Sound Tooth Structure
Orifices location
Restorability Check
Common Outline Form
Common Outline Form
MAXILLARY TEETH MANDIBULAR TEETH
Central incisors Triangular (base: incisal Central incisors Ovoid
area, apex: cervical area)
Lateral incisors Triangular (pulp horns) or Lateral incisors
ovoid
Canines Ovoid (wider Canine
Premolars buccopalatally than MD) Premolars

Molars Triangular or rhomboid Molars Trapezoidal (wider

(MB2) mesiodistally than BL)
Anatomic Considerations
Maxillary
Central ALL MAXI ANTERIORS have a slight distal axial angulation
Lateral Distopalatal canal curvature near the apex
canine Longest root in the arch
1st premolar Roots: buccal, palatal (usually equal in length)
Mesial developmental depression = prone to perforation
2nd premolar Canal/s tend to divide/fuse midroot
1st molar Roots: mesiobuccal, distobuccal, palatal
MB root always has 2 canals
MB2 canal is located palatal to MB1
• most difficult canal to locate = maxi 1st molar has the highest endodontic failure rate

Palatal - widest, has buccal curvature

CROSS-SECTION OF ALL MAXI MOLAR CANALS:
• Oval-shaped with buccopalatal diameter greater than mesiodistal diameter EXCEPT PALATAL CANALS
(still oval but wider mesiodistally)

2nd molar
Anatomic Considerations
MANDIBULAR
Central Pulp chamber is mesiodistally narrow = prone to perforation
Some have 2 canals
Lateral Most common anterior tooth with 2 orifices and 2 canals
Canine Most common bi-rooted anterior tooth
1st premolar Crown is tilted lingually (prone to access prep errors);
may be bifurcated
2nd premolar Apex lies in close proximity to the mental foramen
1st molar Mesial root always has 2 canals
Canals: MB, ML, Distal
Distal canal is the widest and straightest
Distolingual root is common in Asians
2nd molar C-shaped canal; highly variable
2. CHEMOMECHANICAL INSTRUMENTATION- systematic procedure of
removing pulp tissue, debris, and bacteria with the use of files to shape
and irrigants to disinfect the canal

• Pulp Extirpation
• Canal Patency / Glide Path / Canal Scouting
• Radicular Preparation / Crown Down Technique
• Final Working Length Determination
• Apical Preparation / Serial Filing
• Apical Patency Check
 STEPS GOAL INSTRUMENT PROCESS
1. Pup Extirpation Remove vital pulp Appropriate sized barb broach Insert to TWL, should not engage
walls, twist & pull
2. Canal Patency/ Glide Path/ Evaluate diameter and patency of #12, #6, #8, #10 Scout
Canal Scouting canal
3. Radicular Preparation/ Crown Enlarge and flare coronal 2/3 of Largest to smallest files per 1mm -file, irrigate, recapitulate w/ #10,
Down Technique/ Pre-flaring canal to remove bulk of increment irrigate
microorganisms & ensure straight -use smaller size per 1mm
line access to apical region Start: Rx CL + cervical third increment until end of crown
End: Rx CL+ cervical + middle down length
third of root

4. Final Working Length To know the desired end point of File that will bind at estimated -Slightly tap, should not go
Determination apical preparation/ to locate working length beyond estimated working length
apical constriction -rx: 0.5 to 1mm from
radiographic apex

5.Apical Preparation/ Serial Enlarge the apical third of canal IAF to MAF contained at FWL -file, irrigate, recapitulate w/ IAF,
Filing to remove bacteria and debris IAF: measures uninstrumented irrigate
from apical third & create apical width of apical constriction
stop/ matrix MAF: 3-4x size larger than IAF
Possible Apical Configuration at end of Apical
Preparation:
Apical Stop Desired/ ideal; a barrier against
which gutta percha can be
condensed
Apical seat Lack of complete barrier,
instrument placed at length
meets some resistance but goes
beyond he constriction with a
slight tap
Open Apex/ Undesirable/ instrument goes
Blunderbuss apex beyond the apex unimpeded
 STEPS GOAL INSTRUMENT PROCESS
6. Patency Check prevent blockage of apical #10, FWL + 1mm Push file gently
foramen
7. Stepback/ Double Flare the canals to MAF at FWL, then 3-4x -file, irrigate, recapitulate
Flaring optimum level to properly smaller files per 1mm w/ MAF, irrigate
receive the obturating length withdraw
material
8. Circumferential Filing Ensure that debridement MAF at FWL Go around canal to file
& flaring is optimal and away ledges and ensure
obturation will be done glass like feel of the walls
properly
9. Spreader reach test To test if canal is optimally MAF at FWL, #3 spreader Insert MAF at FWL, insert
flared to receive at FWL-1mm spreader at FWL-1mm
obturation
ADA specification no. 28 Length of Cutting edge: 16mm
FILE # = DIAMETER AT ITS TIP
e.g. #30= 0.3mm at its tip

0.02 degree taper means +0.02mm

in diameter every 1mm

0.36mm 0.32mm
0.34mm
 STAINELESS STEEL Manufactured from Motion Notes
K File Skuare SQUARE ROD Watch winding or filing Strongest, can be pre-
curved; more flutes than
reamers so less aggressive
H files ROUND ROD Filing Sharp and efficient
Rhound cutting edge, cuts more
(impossible to withdraw in aggressive than K-files
reaming motion) and reamers
Reamers Triangular TRIANGULAR ROD Clockwise reaming only Less flutes, more
aggressive; also used to
remove obturation
material
Motions of Instrumentation

1. Filing (Circumferential or Anticurvature) Push & pull

2. Reaming/ Rotary CW ¼, pull
3. Watchwind CW/ CCW (30-90°) while advancing
down
4. Balanced Force CW ¼, CCW ¾
Nickel Titanium files
• Milled to different file designs
• Shape memory and superior elasticity so maintains original curvature
of the canal
• flexes when it encounters obstruction like ledges or calcifications
• Used in rotary instrumentation
Faster and more centered canal preparation compared to manual
Reduced likelihood of procedural errors
Ideal tapering of canal for obturation
Less extrusion of debris apically
 Sodium Hypochlorite Hydrogen Peroxide Chlorhexidine EDTA
Concentration 0.5-5.25% 3-5% 2% for RCT 17%
Use Most common Traditionally used in Used in retreatment Chelator/ dentin
conjunction with procedures softener
NaOCl
Advantage -dissolves organic -effervescence -excellent broad -dissolves inorganic
content -bleaching agent spectrum debris
-hemostatic antibacterial agent (enlarge narrow
-effective antibacterial canals & final flush for
agent removal of smear
-good intracanal layer)
lubricant
-affordable
Disadvantage -does not dissolve -weak antibacterial -does not dissolve -no antibacterial
inorganic tissues effect only organic and inorganic activity
-caustic to soft tissues tissues -does not dissolve
NaOCl + CHX= Parachloroaniline -elicits chemical organic tissue
EDTA + NAOCl= deactivation of NaOCl interaction w/ NaOCl
and EDTA
EDTA + CHX= white foggy precipitate
Intracanal medicaments
• Supplement Chemomechanical instrumentation
- Eliminate residual organisms
- Relieve pain
- Manage weeping canals

• Calcium hydroxide- antibacterial & hard tissue formation

• Camphorated monoparachlorophenol (CMCP)
• Mineral Trioxide- also used in repair of perforation and as a root end filling after
apicoectomy
• 2% CHX
 Caries Gram (+) e.g. Streptoccus & Lactobacillus

Primary Infection Gram (-) Anaerobes e.g Bacteroides,

NaOCl
Prevotella, Fusobacterium
/CaOH

Secondary infection/ Gram (+) e.g. Streptococci & Enterococcus

CHX
Persistent Infection faecalis
3. OBTURATION- total obliteration of canal space; sealing the apical
constriction to prevent reinfection of the canal
Criteria for Obturation: ATDOC
1. Asymptomatic
2. Temporary filling intact
3. Dryable
4. Odorless
5. Cleaned and shaped to optimum level
Core filling materials
• Gutta percha cones- thermoplastic, pliable, radiopaque cones
Components: Zinc Oxide, Gutta percha polymer, metal sulfates
Disinfection: immerse in full strength (5.25%) NaOCl for 1 minute
Solvents used during retreatment:
Eucalyptol
Xylol
Chloroform
Turpentine
• Silver cone- rigid, radiopaque cone produced from almost pure silver
Retreatment: retrieved manually via ultrasonic tips, files
Sealer
• Fills irregularities between canal and core material, seals isthmuses
and patent accessory canals, also as lubricant to insertion of cones
• ZOE sealer
Radiopaque
Antimicrobial
Resorbs when extruded into periradicular tissues
Exhibits slow setting time
Cold Lateral Compaction
1. Coat canals with sealer
2. With a pumping motion, slowly advance MAC to FWL
3. Using spreader, MAC is compacted laterally to make room for
accessory canals (minimum spreader size: #25)
4. Add accessory cones until coronal third of canal is reached (apical
2/3 has been obturated)
5. Sear off GP below the orifice level with heated instrument
6. Vertical compaction with plugger to prevent voids in coronal
segment of obturation
Process of Sterilization/ Disinfection
1. Autoclave/ Pressure Steam- 120°C for 20-30 mins, 15 psi
2. Glassbead Sterilizer- 218°C- 232°C
Files: 10-15 seconds
Paperpoints/ Cotton: 5 seconds
3. 2% Glutaraldehyde- 6-10 hrs for heat-sensitive materials
4. Full strength (5.25%) Sodium Hypochlorite
Gutta percha: 1 minute
5. Dry heat- 160°C > 1 hr for sharp-edged instruments
 Endodontic Errors
ACCESS PREP ERRORS Definition Management

1. Gouging Removal of sound dentin on walls of pulp Do not smoothen, restore properly
chamber

2. Perforation Iatrogenic communication between the root Control bleeding if present, locate original
canal system and the external tooth surface canals first, apply MTA, apply tin mix of
CaOH and water, temporize
 CANAL PREP ERRORS DEFINITION MANAGEMENT

1. Ledge formation Iatrogenically created step in the canal wall Smoothen ledge with pre-curved file or
impeding placement of file in canal just obturate until new working length

2. Strip perforation Linear perforation of canal wall due to Control bleeding w/ paper point then
excessive lateral tooth structure removal obturate immediately. If bleeding cannot
be controlled, place CaOH on the side for
2-6 weeks. Remove CaOH, obturate or
apply MTA

3. Zipping Iatrogenic widening of the apex Obturate the best way possible

4. Apical transportation Moving the position of the canal’s Locate the original canal, debride and
physiologic terminus to a new iatrogenic obturate the original canal. Just fill the
location iatrogenically created canal with sealer

5. Apical perforation Transportation extends further creating an Control bleeding, shorten working length,
artificial opening CaOH therapy or obturate ASAP.
6. Overinstrumentation Instrumentation beyond apical Control bleeding. Pack with dentinal chips if
foramen large perforation, or go back to working
length, create an artificial seat by creating
ledge where MAC can seat if small
perforation only
7. Instrument Fracture of instrument within -Best prognosis: Vital & no periapical lesion
Fragmentation canal -General rule: TRY TO RETRIEVE OR BYPASS.
–if not possible, treatment depends on the
stage of canal preparation when it
fractured, pulpal and periapical diagnosis

File anywhere in the canal +Periapical

radiolucency + Minimal canal enlargement
= Periapical tissues have little opportunity
for healing= obturate to point of blockade,
apicoectomy & retrofilling
A fragment of barbed broach is broken off and wedged in the middle third of
a canal of maxillary incisor. Radiolucency is present at the apex. The
fragment cannot be by-passed or removed. Treatment of choice includes
I. Extracting tooth
II. Preparing and obturating to the point of blockade
III. Performing an apicoectomy and retrofilling
IV. Placing formocresol to permeate and fix necrotic

a. 1,2,3
b. 1, 2
c. 2,3
d. 2,3,4
e. 3 only
 OBTURATION ERRORS MANAGEMENT
1. Underfill Re-obturate
2. Overfill Observe. If symptoms develop,
surgical endodontics
3. Void Re-obturate if middle & apical
third; add more accessory
cones prior to sear off if coronal
Outline
I. Pulp X. Procedural Errors
II. Morphology of the Root Canal XI. Endodontic Surgery
System XII. Dentoalveolar Injuries
III. Diagnostic Testing XIII.Endodontic Periodontal Lesions
IV. Pulp Pathologies XIV.Tooth Bleaching
V. Periapical Pathologies XV. Restoration of Endodontically
VI. Pulp Therapy Procedures Treated Tooth
VII. Root Canal Treatment
VIII. Irrigants
IX. Root Canal Medicaments
ENDODONTIC SURGERIES
1. Surgical drainage
- Incision & Drainage
-Cortical Trephination
2. Periapical Surgery
-Apical Curettage
- Apicoectomy (Root-End Resection)
3. Corrective Surgery
- Root amputation (Root resection)
-Bicuspidization
- Hemisection
4. Intentional Replantation
Surgical Drainage

Incision and Drainage Cortical Trephination

Apical Curettage

Apicoectomy:
1. Post-restored tooth that needs retreatment
2. Broken instrument at the coronal/middle
third of canal where retrieval and bypass are
not possible

-root amputation: 3mm

-retropreparation: 3mm, 0- 10°
-retrofilling: Zn free Am, SuperEBA, MTA
 Hemisection

Bicuspidization
Intentional Replantation
Full Mucoperiosteal Flaps
1. FULL MUCOPERIOSTEAL FLAPS
a. horizontal
b. trapezoidal
c. triangular

ADV:
-accessibility and visibility
DIASDV:
-possible post surgical recession
-difficult to reposition
Limited Mucoperiosteal flap

Submarginal Scalloped/ Ochsenbein Luebke Submarginal Curved/ Semilunar/ Half moon

ADV: DISADV:
-less risk of incising over bony defects -limited access & visibility
-no post-surgical recession of gingiva -if somehow the lesion is bigger than
-recommended for apical surgery anticipated, the incisions come to lie over the
bony defect
DISADV: -extent limited by attachment
- Hemorrhage from cut margins and scarring -not used for anterior root-end surgery because
of excessive tissue shrinkage & formation of
obvious scar
Outline
I. Pulp X. Procedural Errors
II. Morphology of the Root Canal XI. Endodontic Surgery
System XII. Dentoalveolar Injuries
III. Diagnostic Testing XIII.Endodontic Periodontal Lesions
IV. Pulp Pathologies XIV.Tooth Bleaching
V. Periapical Pathologies XV. Restoration of Endodontically
VI. Pulp Therapy Procedures Treated Tooth
VII. Root Canal Treatment
VIII. Irrigants
IX. Root Canal Medicaments
Ellis Classification of Traumatic Injuries

NARDCP
Reminders:
• EPT is unreliable for recent trauma cases
• Mobile segments- reattach and stabilize with a splint
• Pain upon biting/ positive to percussion- disocclude

• Treatment considerations:
 Stage of tooth development
Vital immature- promote apexogenesis, vital immature- promote apexification
Time between accident and treatment
With periodontal injury= high possibility of necrosis
 need for complex restoration requires RCT
A 12 year old boy has arrived in your office after a fall that fractured
tooth #9 up to the gingival margin on the mesial aspect with pulp
exposure. What is the appropriate treatment?
a. Extraction
b. Pulpotomy
c. DPC
d. RCT
e. Apexogenesis
• Infraction- without loss of tooth structure
 incomplete crack of enamel
 craze lines in enamel that do not extend into dentin
• Uncomplicated crown fractures- with loss of tooth structure but
without pulp involvement
 prognosis is good
Treatment is smoothening the rough edges or restoring lost structure
COMPLICATED CROWN FRACTURE CROWN-ROOT FRACTURE ROOT FRACTURE LUXATION AVULSION
Immature, Vital: w/o pulp exposure: w/o displacement of Concussion & Subluxation: Extraoral Drytime <1hr
<2 days- DPC/ CaOH Stabilize coronal fragment coronal part: splint for 2 weeks for comfort Immature:
pulpotomy depending on pulp to adjacent tooth part or Disocclude Attempt revascularization
(Minocycline + saline),
exposure size restore Extrusive & Lateral: Rinse, replant, splint for 2
w/ displacement: Splint then follow up if for wks, Recall if
>2 days- Pulpotomy w/ pulp exposure: Splint (4 wks to 4 RCT revascularization is
Immature, Vital: partial months) then follow up successful. If not,
pulpotomy if for RCT Intrusive: apexification for RCT
Immature tooth, Necrotic: Immature, Necrotic: Immature:
Apexification & Pulpectomy . <7mm- spontaneous Mature: Saline, replant,
Apexification/ splint for 2 wk, Start w/in
Revascularization eruption; if not, ortho a week RCT, CaoH for 4
>7mm-surgical/ortho wks before obturation
Mature: RCT, PCC
Mature:
<3mm, <17y/o- spontaneous Extraoral Drytime >1hr
Immature: remove dead
Mature, Vital: euption w/in 2-3 weeks; if
PDL cells w/ gauze, RCT
<24 hrs, simple resto: DPC not, ortho/surgery extraorally, replant, splint
<24 hrs, PCC: RCT 3-7mm- reposition w/in 3 for 4 wks
>24 hrs: RCT weeks ortho/surg
>7mm- surgery Mature: remove dead PDL
cells w/ gauze, immerse in
Mature, Necrotic: RCT Recall if needs RCT after 2% NaF, RCT prior to
replantation, splint, CaOH
repositioning
for 4 wks before
obturation

Prepare socket: Anes &

 COMPLICATED CROWN FRACTURE CROWN-ROOT FRACTURE ROOT FRACTURE
Immature, Vital: w/o pulp exposure: w/o displacement of coronal part:
<2 days- DPC/ CaOH pulpotomy depending on Stabilize coronal fragment to adjacent Disocclude
pulp exposure size tooth part or restore
w/ displacement:
>2 days- Pulpotomy w/ pulp exposure: Splint (4 wks to 4 months) then
Immature, Vital: partial pulpotomy follow up if for RCT
Immature, Necrotic: Apexification &
Pulpectomy .
Immature tooth, Necrotic:
Apexification/
Revascularization

Mature: RCT, PCC

Mature, Vital:
<24 hrs, simple resto: DPC
<24 hrs, PCC: RCT
>24 hrs: RCT

Mature, Necrotic: RCT

 LUXATION AVULSION
Concussion: Disocclude, for 2 weeks for comfort Extraoral Drytime <1hr
Subluxation: Disocclude, splint for 2 weeks Immature:
Attempt revascularization
Extrusive & Lateral: (Minocycline + saline), Rinse, replant, splint for 2 wks, Recall if
Reposition, splint then follow up if for RCT revascularization is successful. If not, apexification for RCT

Intrusive: Mature: Saline, replant, splint for 2 wk, Start w/in a week RCT,
Immature: CaoH for 4 wks before obturation
<7mm- spontaneous eruption; if not, ortho HBS- 3 days
>7mm-surgical/ortho
Milk- 3 hrs
Mature:
<3mm, <17y/o- spontaneous euption w/in 2-3 weeks; if not,
Saliva- 2 hrs
ortho/surgery Saline- 2hrs
3-7mm- reposition w/in 3 weeks ortho/surg Extraoral Drytime >1hr
>7mm- surgery Immature: remove dead PDL cells w/ gauze, RCT extraorally,
replant, splint for 4 wks
Recall if needs RCT after repositioning
Concussion Subluxation Luxation Mature: remove dead PDL cells w/ gauze, immerse in 2% NaF, RCT
prior to replantation, splint, CaOH for 4 wks before obturation
Percussion + + +
Mobility - + + (except Prepare socket: Anes & irrigate
lateral)
Displacement - - +
• Alveolar fracture
Clinical sign: malocclusion, multiple adjacent teeth move as one unit
Management: reduction and fixation (rigid splint)
Type of Trauma Type of Splint Duration of immobilization
Concussion, Subluxation Flexible 2 weeks
Extrusive Luxation Flexible 2 weeks
Avulsion Flexible 2 weeks
Lateral Luxation Flexible 4 weeks
Fracture of middle third of root Rigid 4 weeks
Fracture of cervical third of root Rigid 4 weeks- 4months (depends on
mobility or coronal segment)
Fracture of Alveolar process Rigid 4 months
Outline
I. Pulp X. Procedural Errors
II. Morphology of the Root Canal XI. Endodontic Surgery
System XII. Dentoalveolar Injuries
III. Diagnostic Testing XIII.Endodontic Periodontal
IV. Pulp Pathologies Lesions
V. Periapical Pathologies XIV.Tooth Bleaching
VI. Pulp Therapy Procedures XV. Restoration of Endodontically
VII. Root Canal Treatment Treated Tooth
VIII. Irrigants
IX. Root Canal Medicaments
 Endo-Perio Lesions 1. To differentiate endo and perio
lesions:
-vitality test
(+) periodontal
(-) endodontic
-Probing
Narrow Deep Pocket Endodontic in nature/
-sinus Vertical fracture
-blowout
-precipitous drop

Broad-based pocket Periodontal in nature

-conical

2. Treatment always starts w/ RCT!

Outline
I. Pulp X. Procedural Errors
II. Morphology of the Root Canal XI. Endodontic Surgery
System XII. Dentoalveolar Injuries
III. Diagnostic Testing XIII.Endodontic Periodontal Lesions
IV. Pulp Pathologies XIV.Tooth Bleaching
V. Periapical Pathologies XV. Restoration of Endodontically
VI. Pulp Therapy Procedures Treated Tooth
VII. Root Canal Treatment
VIII. Irrigants
IX. Root Canal Medicaments
 Bleaching technique
Intracoronal (Non-Vital) Extra- coronal (Vital)

Chair-side Superoxol Superoxol

(in-office) (i.e. thermocatalytic)

At-home Sodium perborate Carbamide peroxide

(i.e. walking bleach technique) (i.e. custom tray
technique)
Complications External Cervical resorption, Transient sensitivity
acute apical periodontitis

HYDROGEN PEROXIDE CONTENT:

Superoxol: 30%
Sodium perborate: 3-7.5%
Carbamide peroxide: 10-22%
Post placement:
1. Minimum: 4-5mm gutta percha
2. Length: at least equal to crown length, >1/2- 2/3 of remaining root,
extends ½ length of root supported by bone
3. < 1/3 of root width at its narrowest dimension, should have 1mm
remaining dentin thickness
4. Mx molar- palatal canal, Md molar-distal canal
 Resorption Rationale Result
1. Internal Resorption Chronic irreversible pulpitis, trauma, -PINK tooth due to growth of
caries, pulp capping w/ CaOH, granulation tissue undermining
cracked tooth coronal dentin
2. External Resorption trauma, periradicular inflammation,
excessive ortho forces, impacted
teeth, internal bleaching of nonvital
teeth
a. Inflammatory Due to the infected/ necrotic pulp -Progressive bowl shaped area of
resorption involving cementum and
dentin
b. Surface Acute injury to PDL and root surface -Very common, self-limiting,
reversible

c. Replacement Bone replaces dentin -Ankylosis

d. Invasive Cervical Resorption unknown -Uncommon, insidious, aggressive

form
“One day you will find yourself at the very center of that thing you are
praying for.”