V
Author Arnaldo Castellucci Dr. Castellucci graduated cum laude in Medicine at the University of Florence in 1973 and he specialized in Dentistry at the same University in 1977. From 1978 to 1980 he attended Continuing Education Courses in Endodontics at Boston University School of Graduate Dentistry with Prof. Herbert Schilder and in 1980 he spent four months in Professor Schilder’s Endodontics Department, where he practiced on patients and carried out research on the Scanning Electron Microscope. Since then, he runs a practice limited to Endodontics. Dr. Castellucci is Past President of the Italian Society of Endodontics (SIE) and Active Member of the European Society of Endodontology (ESE), where he served as Secretary from 1981 to 1983. Since 1985 he has been an Active Member of the American Association of Endodontists (AAE). He was President of the International Federation of Endodontic Associations (IFEA) from 1990 to 1992. From 1983 to 2000 he was Adjunct Professor of Endodontics at the University of Siena Dental School and from 2001 to 2014 Adjunct Professor of Endodontics at the University of Florence Dental School. He is currently Adjunct Professor of Endodontics at the University of Cagliari Dental School and since 2008 he is Professor of Surgical Endodontics for the postgraduate course in Oral Surgery at the Federico II University of Naples. Honorary Member of the Ukrainian Medical and Stomatological Academy. He is the Italian translator of “Clinical and Surgical Endodontics. Concepts in Practice”, by Frank, Glick, Simon and Abou-Rass published by Piccin. He was Editor-in-Chief of the Italian Journal of Endodontics, Giornale Italiano di Endodonzia, and Chief Scientific Director of Informatore Endodontico. He is also the Founder and President of the “Warm Gutta-Percha Study Club”. He is currently Editor-in-Chief of Endo Tribune and Scientific Consultant to the journals Endodontic Practice, Endodontic Practice US and is a member of the Editorial Board of Clinical Dentistry. Dr. Castellucci is also the Founder and Chairman of the Micro-Endodontics Training Center, based in Florence, where he teaches and holds hands-on courses in Clinical and Surgical Endodontics. He has published more than 60 articles in the most prestigious Endodontic Journals. In 1993 he published the textbook EndodonziA (Ed. Martina, Bologna), which was updated and translated into English in 2004 with the title EndodonticS (Ed. Martina, Bologna).
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He is also the author of Microsurgical Endodontics, published by Edra and available also in Italian and Spanish. He authored the chapter on “Obturation of the radicular spaces” for the seventh edition of Ingle’s Endodontics published by PMPH USA, Ltd. North Carolina, the chapter on “Internal Tooth Anatomy and Root Canal Obturation” for The Root Canal Anatomy in Permanent Dentition, published by Springer, and the chapter on “Endodontic-periodontal relationships” for Periodontal diagnosis and therapy published by Quintessence. With Professor Elio Berutti, he co-authored the chapter on “Non-surgical Root Canal Retreatment” for The Guidebook to Molar Endodontics published by Springer. A lecturer of international standing, Dr. Castellucci has given presentations at national and international conferences in more than 65 countries worldwide. He has taught courses and lectured on a number of topics, such as orthograde endodontics, surgical endodontics, retreatments, CBCT, instrumentation with NiTi, new technologies and the use of the operating microscope. He has also taught practical courses on nonsurgical as well as surgical endodontics, both abroad and in Italy at his Micro-Endodontics Training Center, based in Florence. He can be reached by email at castellucciarnaldo@gmail.com or via his website www.endocastellucci.com.
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Co-Authors Dr. Laura Garcia Aguilar
Prof. Elio Berutti, MD, DDS
Graduate in Endodontics at the European University of Madrid. MSD in minimally invasive pediatric dentistry at the training center of Dr. Patrizia Gatòn. Member of the Italian Society of Pediatric Dentistry (SIOI), Dr. Aguila has studied lactation at Dr. Camila Palma’s Chis Dental practice. Dr. Aguilar maintains a clinical practice limited to pediatric dentistry in Bari, Italy.
Graduate in Medicine and specialized in Odontostomatology at the University of Turin. Private Practice limited to Endodontics in Turin. Full Professor of Endodontics and Restorative Dentistry for the master’s degree Course in Dentistry and Dental Prosthetics at the University of Turin. Director of the C.I.R. Dental School at the University of Turin. President of the master’s degree course in Dentistry and Dental Prosthetics of the University of Turin. Director of the master’s degree course in Clinical and Surgical Micro-endodontics at the University of Turin. Director of the SCDU (Complex Structure under University Management) of Preventive and Restorative Odontostomatology at the City of Health and Science Hospital of Turin. Past President of the Italian Society of Endodontics (SIE). Active Member of the European Society of Endodontology (ESE). Member of the American Association of Endodontists (AAE). Professor Berutti has published a number of articles in the most prestigious Italian and foreign journals of endodontics and has lectured at courses and conferences in Italy and abroad.
Dr. Mario Alovisi DDS, PhD Dr. Alovisi graduated cum laude in Dentistry at the University of Turin in 2010. Since 2013 is Consultant in the Post-Graduate Master Course in Micro-Surgical Endodontics at the University of Turin. Since 2014 is official Consultant medical staff at the CIR Dental School of Turin. In 2016 he obtained the PhD Program Degree in Technologies Applied to Surgical Sciences for regenerative procedures in Endodontics at the University of Turin. Since 2018 is Confirmed Researcher in Odontostomatology and from 2021 is Associate Professor of the Department of Surgical Sciences at the University of Turin. He is author of original papers and review articles on peer-reviewed journals on different aspects of Endodontics and Operative Dentistry. He can be reached by email at mario.alovisi@ unito.it
Prof. Ana Arias, DDS, MS, PhD Professor and Director of the Postgraduate Program in Endodontology at Complutense University, Madrid, Spain. Specialized in Endodontics. PhD in Dentistry. Postgraduate Diplomate in Statistics and Study Design for Health Sciences. Master of Science in Medical Education Leadership. Private Practice limited to Endodontics. International lecturer and author of multiple papers in Endodontics.
Dr. Caterina Chiara Bianchi Graduate cum laude in Medicine at the University of Turin and specialized cum laude in Radiodiology. Teacher at the Master’s degree course in Oral Surgery, master’s degree course in Orthosurgery, degree course in Dentistry and Dental Prosthetics and degree course in Dental Hygiene at the University of Turin. Since 2017-2018 she has been responsible for the course of radiology at the School of Specialty in Ortho-pedodontics and from Since 2020-2021 Dr. Bianchi has been responsible of the course in Diagnostic Imaging and Radiation Protection in Odontostomatology at the degree course in Dentistry and Dental
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Co-Authors
Prosthetics of the faculty of Medicine and Surgery of the University of Turin. Ordinary member of the Italian Society of Medical Radiology (SIRM). She practices at the Radiology Department of the Dental School of Turin.
Dr. Uziel Blumenkranz, DDS, MScD Graduate in Dentistry at Universidad Central de Venezuela. Specialized in Endodontics at the Henry M. Goldman School of Graduate Dentistry, Boston MA. Certificate of Advanced Graduate Studies in Endodontics, Master of Science in Dentistry. He maintained a practice limited to Endodontics in Caracas, Venezuela between 1978-2002. Past President of the Venezuelan Society of Endodontics. President of the Organizing International Symposium on Endodontics. Invited lecturer at the Post Graduate Program of Endodontics Universidad Central de Venezuela. National and international lecturer in endodontics. Dr. Blumenkranz is an Honorary Member of several Endodontic Societies, Life Member of the American Association of Endodontists, Member of the American Dental association, The DC Dental Society, Alpha Omega and several other Endodontic Societies and Study Clubs. He has his practice limited to Endodontics in Washington DC (USA).
Dr. L. Stephen Buchanan, DDS, FICD, FACD He is a diplomate of the American Board of Endodontics. Founder of the Dental Education Laboratories. Lecturer and teacher of hands-on endodontic continuing education courses for over 30 years at his state-ofthe-art training facility in Santa Barbara, California (USA) as well as in dental schools and meetings around the world. He is wellknown both nationally and internationally as an expert in the research and development of new technology, new instruments and new techniques in the field of Endodontics.
Prof. Giuseppe Cantatore, MD, DDS Graduate in Medicine and Specialized in Dentistry at the University of Rome “La Sapienza”. He has been Professor of Endodontics at the University of L’Aquila, “La Sapienza” of Rome and at the University of Verona. He is currently Professor of Endodontics and Restorative Dentistry at the Life-Health University San Raffaele in Milan. Author of more than one hundred articles related to Endodontics published in national and international dental journals. International speaker, presented at courses and congresses in more than 40 different countries around the world. Past-President of the European Society of Dental Microscopy (EFAM), Past President of the Italian Society of Endodontics (SIE), Past President of the Italian Association of Dental Microscopy (AIOM). He lives and works in Rome with a clinical practice limited to Endodontics.
Dr. Francesca Cerutti, DDS, PhD Graduate cum laude in Dentistry at the University of Brescia in 2007. In 2013 she obtained her PhD in Materials for Engineering and in 2016 a two-year master’s degree in Aesthetic Medicine. Dr. Cerutti is Member of the Italian Society of Endodontics and Gold Member of Style Italiano Endodontics.
Dr. Kirk A. Coury, DDS, MS, FICD, FACD Graduate at the Baylor College of Dentistry. Certificate in Endodontics and Master’s Degree in Dentistry at the University of Texas Health Science Center, Houston (USA). Active Member of the American Association of Endodontists and of the Foundation for Endodontics. Dr. Coury is Diplomate of the American Board of Endodontics and Fellow of the American and International College of Dentists. He maintains a private practice limited to Endodontics in Amarillo, Texas.
Co-Authors
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Dr. Paolo Ferrari, DDS, LMD
Dr. Stefania Multari, DDS
Graduate in Dentistry from the University of Parma in 1988. Graduate in Dentistry at the Université de Genève (Switzerland) in 1993, obtaining the Swiss Degree in Dental Medicine (LMD). Active member of the Italian Academy of Conservative Dentistry (AIC), of the Italian Academy of Endodontics (AIE) and of the Italian Society of Endodontics (SIE). Visiting Professor of Operative Dentistry at the University of Parma, Dental School. Dr. Ferrari has authored articles in national and international journals, is a lecturer at courses and congresses and maintains a private practice in Parma.
Graduate cum laude in Dentistry at the University of Turin, where she is currently completing a PhD program in Bioengineering and Medical-Surgical Sciences at the University of Turin in collaboration with the Polytechnic of Turin. She works as a consultant in Endodontics and Restorative Dentistry in Turin and Reggio Calabria. Member of the Italian Society of Endodontics (SIE) and of the Italian Academy of Restorative Dentistry (AIC).
Dr. Mario Lendini, DDS Graduate in Dentistry at the University of Turin. Certified Member of the European Society of Endodontology (ESE) since 1997, member of the American Association of Endodontists (AAE) since 2006, member of the Italian Academy of Microscopic Dentistry (AIOM), of which he was President from 2008 to 2010, President Elect, to take office from 2023 to 2024, of the Italian Society of Endodontics (SIE). Co-author of specialist texts on endodontics and surgical microscopy and of articles in Italian and international scientific journals. Lecturer and scientific coordinator at over 700 Italian and international cultural events. Dr. Lendini maintains a private practice in Turin focusing on clinical and surgical endodontics and implantology.
Prof. Pierre Machtou, DDS, MS, PhD, FICD Graduate at the ParisVII-Denis Diderot University, where he also received the MS degree in 1980 and PhD in 1977. He has served as full Professor of Endodontics at the same University from 1997 to 2011, as Vice-Dean from 1998 to 2008 and was awarded Professor Emeritus in 2011. Professor Machtou is currently Professor of Endodontics at the Université de Genève.
Dr. Matteo Papaleoni DDS Graduate in Dentistry at the University of Florence Dental School. He obtained a 2nd level Master Degree in Endodontics and Restorative Dentistry at the University of Siena. He works as a consultant in the office of Dr. A. Castellucci with a special focus on aesthetic dentistry and tooth restoration using minimally invasive techniques. Dr. Papaleoni is a lecturer at Dr. A. Castellucci’s courses on “Restoration of the endodontically treated tooth” and “Endodontic obturation with the Thermafil system”. He is active member of the Italian Society of Endodontics (SIE), he has contributed to drafting a number of scientific articles concerning endodontics. He is a teacher on the 2nd Level Master Degree Course on Restorative Dentistry and Endodontics at the University of Siena, author of chapters on Restorative Dentistry for Dr. A. Castellucci’s book “Endodontics Compendium” published by Martina, Bologna and co-author of several chapters in the books “Surgical Micro Endodontics” and “Endodontics”, both published by EDRA. He is a member of the “Cultural Commission” of SIE for the current two-year-period 2021-2022 and opinion leader for Dentsply Sirona.
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Co-Authors
Dr. Damiano Pasqualini, DDS Graduate in Dentistry at the University of Turin Dental School in 1995. Associate Professor in Endodontics at the University of Turin, Department of Surgical Sciences (Director Prof. S. Carossa), CIR Dental School (Chairman Prof. E. Berutti), Centre for Clinical and Surgical MicroEndodontics. Co-director of the International Post-graduate Master Program in Clinical and Surgical MicroEndodontics at the University of Turin. Dr. Pasqualini has hi private practice in Turin, limited to Clinical and Surgical Micro-Endodontics. Active Member and past member of the Board of Directors of the Italian Society of Endodontics (SIE), international member of the American Association of Endodontists (AAE). Dr. Pasqualini is the author of a numerous manuscripts of published on impacted international journals. Member of the editorial board and reviewer of international journals. Co-author of book chapters on Endodontics, Cariology and Preventive Dentistry and lecturer at national and international congresses.
Dr. Stefano Patroni, MD, DDS, LMD Graduate cum laude in Medicine at the University of Parma. Graduate in Dental Medicine at the Université de Genève (Switzerland). Teacher at the Post-Graduate Program in Implantology at the Universities of Parma, Modena and Reggio Emilia. Assistant Professor in “Fixed Prosthetics” at the University of Parma Dental School. Teacher of the 2nd Level Master Degree Program in Aesthetic Restorative Dentistry at the “Alma Mater Studorium”, University of Bologna. Active member of the Italian Academy of Restorative Dentistry (AIC). Dr. Patroni served as AIC Vice president 2000-2003 and AIC President 2016-2017.
Prof. Ove Peters, DMD (Univ. Kiel), MS (UCSF), PhD (med dent habil Univ. Zurich) Discipline lead and Professor of Endodontics at the University of Queensland School of Dentistry, Australia. Academic Director, OHA. Certified as a Diplomate of the American Board of Endodontics. Professor Peters has wide-ranging research expertise and has published more than 175 manuscripts related to endodontic technology and biology.
Dr. Andrea Polesel, DDS Graduate in Dentistry at the University of Genoa. Active Member of the Italian Society of Endodontics (SIE) and of the Italian Academy of Restorative Dentistry (AIC), Certified Member of the European Society of Endodontology (ESE), and International Member of the American Association of Endodontists (AAE). Member of the Board of Directors of the Italian Society of Endodontics (SIE). Adjunct Professor of Endodontics at the University of Genoa. International lecturer, Dr. Polesel gave presentations in Iran, Egypt, Dubai, Bahrain, Lebanon, Qatar and Kuwait. He is the author of articles, book chapters and is the co-author of books on endodontics and restorative dentistry. He has his private practice in Arenzano (Genoa, Italy).
Dr. Clifford J. Rudle, DDS, FICD, FACD Founder and Director of the Advanced Endodontics (www.endoruddle.com), an international educational source in Santa Barbara, California. Creator of the Ruddle Show (www.theruddle- show. com). As an inventor, Dr. Ruddle has designed and developed products that are used internationally. He is well-known for providing endodontic education through his teaching, articles, and online presence.
Co-Authors
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Dr. Filippo Santarcangelo, DDS
Prof. John Stropko, DDS
Graduate summa cum laude in Dentistry at the “Aldo Moro” University of Bari, Dental School. Adjunct Professor at the University of Padua Dental School from 2011 to 2019. Professor of the Two-year Postgraduate Course in Endodontics at the Rey Juan Carlos University Hospital in Madrid. Dr. Santarcangelo has his private practice in Bari, limited to micro-clinical and -surgical endodontics.
Dr. Stropko received his DDS from Indiana University in 1964. He served in the United States Air Force as a captain in the Dental Corps. After practicing in general and restorative dentistry until 1987, in 1989 he received a Certificate for Endodontics, from Dr. Herbert Schilder, at Boston University, and returned to private practice, as an endodontist, for the next 23 years. Speaker and internationally recognized authority in the field of Conventional and Micro-Surgical Endodontics. Visiting Clinical Instructor at the Pacific Endodontic Research Foundation (PERF). Adjunct Assistant Professor at Boston University (USA), Assistant Professor of Graduate Clinical Endodontics at Loma Linda University (USA) and was on the endodontic faculty at the Scottsdale Center of Dentistry, responsible for the Micro-Surgical curriculum. His clinical research on “in-vivo root canal morphology” has been published in the Journal of Endodontics; and, wrote the Micro-Surgery chapter, in Vol. III of Arnaldo Castellucci’s textbook, “Endodontics”. Dr. Stropko is the inventor of the Stropko Irrigator and was the co-founder of Clinical Endodontic Seminars. Author of the chapter on microsurgery in the 3rd volume in the “Endodontics” series by Dr. Arnaldo Castellucci. Over the past two decades, he has given numerous presentations and live Conventional and Surgical Micro-Endodontic demonstrations worldwide. He is currently Director of the Horizon Dental Institute in Scottsdale, Arizona (USA).
Dr. Michael Scianamblo, DDS Endodontist and developer of the Critical Path Technology. He is a post-graduate and fellow of the Harvard School of Dental Medicine and has served as a faculty member of the University of the Pacific and the University of California, Schools of Dentistry in San Francisco. He has also served as President of the Marin County Dental Society, the Northern California Academy of Endodontists and the California State Association of Endodontists. He has presented numerous lectures nationally and internationally, and is a recognized author in endodontics, dental materials, and instrumentation. He maintained a private practice in endodontics in San Francisco and Marin County, California, since 1978. His career is currently dedicated to instrument development, and he has been awarded twelve U.S. patents and two international patents with several patents pending.
Prof. Nicola Scotti, DDS, PhD Graduate in Dentistry at the University of Ferrara Dental School. PhD at the PhD School in Nanotechnology of the University of Trieste. Director of the Master Degree Program in Restorative Dentistry and Aesthetics at the University of Turin. Associate Professor at the University of Turin, Department of Surgical Sciences Dental School, Endodontics and Operative Dentistry.
Dr. Yoshi Terauchi, DDS, PhD He completed his residency at Tokyo Medical & Dental University in 1995, where he also received his PhD from the Department of Endodontics. He is author of a number of chapters in textbook on endodontics, including the 11th and 12th editions of Pathways of the Pulp and the 6th edition of Endodontics, Principles and Practice.
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Prof. Peet Van Der Vyver, DDS, BChD Endodontist based in Sandton, Johannesburg, South Africa and director of the Studio for Endodontics, Restorative Dentistry and Dental Education. He is a Postgraduate and Faculty Member of the University of Pretoria, South Africa, where he is currently appointed as an extra-ordinary Professor in the Department of Odontology, School of Dentistry, University of Pretoria, South Africa. Recognized author in the endodontic literature, he has lectured extensively at national and international congresses. He is the past President of the South African Academy of Aesthetic Dentistry (SAAAD) and is currently the President of The South African Society for Endodontics and Aesthetic Dentistry (SASEAD).
Dr. Julian Webber, MS, BDS, FICD Master’s degree in Endodontics from Northwestern University Dental School, Chicago. Lectured extensively and gave many handson courses at a number of international conferences worldwide. Author of articles for a numerous peer reviewed scientific journals and contributor of numerous chapters in endodontic texts. Past President of the British Endodontic Society and of the American Dental Society of London. Faculty Member of
the Pacific Endodontic Research Foundation (PERF) of San Diego, California. Honorary Professor of the University of Belgrade, Serbia. Honorary Member of the Ukrainian Medical and Stomatological Academy. Fellow of the International College of Dentists (FICD). Active Member of the American Association of Endodontists (AAE). Dr. Webber was the editor of the UK journal “Endodontic Practice” and a board member of several prestigious dental journals. The co-developer of the single file reciprocating system, WaveOne® Gold, Dentsply Sirona, he maintains a private practice limited to Endodontics in London.
Dr. John West, DDS, MSD, FICD Founder and Director of the Center for Endodontics. Educator in clinical and interdisciplinary endodontics. He received his DDS from the University of Washington in 1971 where he is an Affiliate Associate Professor. He then earned his MSD in endodontics at the Boston University Henry M. Goldman School of Dental Medicine in 1975, where he is a clinical instructor and has been awarded the Distinguished Alumni Award. He has presented unrivaled endodontic continuing education in North America, South America, Europe, and Asia. He maintains a private practice in Tacoma, Washington (USA).
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Table of contents Foreword to the first Italian edition by H. Schilder . . . . . . . . . . XXV Foreword by J. West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XXVII Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XXIX
Volume 1 Chapter 1
Chapter 4
A brief history of Endodontics . . . . . . . . . . . . . . . . . . . . 3
Diagnosis in Endodontics . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Arnaldo Castellucci
Arnaldo Castellucci
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Subjective information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Medical history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Chapter 2
Tooth embryology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Arnaldo Castellucci
Dental history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Objective information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Percussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Palpation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Crown formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Radiographic examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Root formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Digital radiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Single- and multiple-root formation . . . . . . . . . . . . . . . . . . . . . . . . . 19
Cone Beam Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . 68
The formation of lateral canals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Exposed dentin and enamel pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Function and fate of dental lamina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Thermal tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Electric pulp test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Cavity test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Anesthesia test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Transillumination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Bite test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Chapter 3
Definition, scope, and indications for endodontic therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Arnaldo Castellucci
Basic phases of endodontic therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Indications and contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Chapter 5
Endodontic radiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Arnaldo Castellucci
How X-rays were discovered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
True contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Basic principles of radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
False contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Principles of X-ray formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
True indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
The quality of the radiograph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Strategic Endodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Factors controlling the X-ray beam . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Kilovoltage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
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Exposure time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Radiation dose considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Milliamperage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Pixel and voxel information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Filter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Evaluation of periapical status: conventional radiography . . . . . . 176
Collimator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Evaluation of periapical status: CBCT scans . . . . . . . . . . . . . . . . . . . 182
Target-object distance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Tooth morphology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Basic principles of image formation . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Vertical root fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Image sharpness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Dental trauma and root resorptions . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Image magnification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Micro-surgical Endodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Image distortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Intraoperative endodontic applications of CBCT . . . . . . . . . . . 203
Intraoral radiographic techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Endodontic perforations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Bisecting angle technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Endodontic material extending beyond the root canal . . . . . . . . . . 210
Paralleling technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Fractured instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Spatial localization: buccal object rule . . . . . . . . . . . . . . . . . . . . . . . 99
Calcified canals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Radiographic orientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Endoral radiographic examinations . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Preoperative or diagnostic radiographs . . . . . . . . . . . . . . . . . . . . . . . 109
CBCT imaging in children for endodontic purposes . . . . . . . . . . . . 214
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Intraoperative radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Common causes of errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Chapter 8
Protection of the patient, dentist, and auxiliary personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Pulpal pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Arnaldo Castellucci
The reparative capacity of pulp tissue . . . . . . . . . . . . . . . . . . . . . . . . 221 Chapter 6
Digital radiographic systems . . . . . . . . . . . . . . . . . . . . 139 Mario Lendini, Stefania Multari
The origin and technological evolution . . . . . . . . . . . . . . . . . . . . . . 140 Characteristics of RVG images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Pulpal diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 Clinical classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 Vital pulp therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 Pulp capping with MTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 MTA Carriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Reading and elaboration of DRS images . . . . . . . . . . . . . . . . . . . . . . . 150 Quality of DRS images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Time of execution and elaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Dosage amounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Fundamental quantities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Adaptation and repeatability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Chapter 9
Periapical disease and the “Cracked Tooth Syndrome” . . . . . . . . . . . . . . . 255 Arnaldo Castellucci, Uziel Blumenkranz, Matteo Papaleoni
Archiving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Section I – Periapical disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
The large formats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Arnaldo Castellucci
The microCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
The reparative capacity of periapical tissues . . . . . . . . . . . . . . . . . 255 Classification of the lesions of endodontic origin . . . . . . . . . . . 260 Chronic apical periodontitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Chapter 7
The use of Cone Beam Computed Tomography (CBCT) in clinical and surgical endodontics . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Damiano Pasqualini, Mario Alovisi, Caterina Chiara Bianchi, Arnaldo Castellucci
Reactivation of chronic apical periodontitis . . . . . . . . . . . . . . . . . . . 291 Acute apical periodontitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292 Acute alveolar abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Section II – The “Cracked Tooth Syndrome” . . . . . . . . . . . . . 298 Uziel Blumenkranz
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
Basic principles of CBCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
Field of view (FOV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Table of contents
XV
Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Lubricant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
Clinical findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
Rubber dam napkins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304 Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308 Class I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
Dental floss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376 Assistant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
Positioning of the dam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
Class II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310 Class III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Chapter 12
Class IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Access cavity and endodontic anatomy . . . . 393
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Section III – Rrestoration of “The Cracked Tooth” . . . . . . .
313
Elio Berutti, Arnaldo Castellucci
Requirements of the access cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Matteo Papaleoni
Permit the removal of all the chamber contents . . . . . . . . . . . . . . 393
Class I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Permit complete, direct vision of the floor of the pulp chamber and canal openings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
Class II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Chapter 10
The use of anesthesia in Endodontics . . . . . . . 331 Arnaldo Castellucci, Kirk A. Coury, Francesca Cerutti
Topical anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331 Local infiltration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Facilitate the introduction of canal instruments into the root canal openings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395 Provide access as direct as possible to the apical one third of the canal for both preparation instruments and canal filling instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395 Provide a positive support for temporary fillings . . . . . . . . . . . . . . 397 Always have four walls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397 Mini-invasive access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
Rules for the preparation of an adequate access cavity . . . . . . 400 General principles for the preparation of the access cavity . . . 401 Penetration phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
Regional anesthesia or nerve blocks . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Final shape and finishing of access cavity . . . . . . . . . . . . . . . . . . . . 402
Inferior alveolar nerve block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Mental nerve block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
Upper central incisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
Nasopalatine nerve block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
Upper lateral incisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412
Anterior and middle superior alveolar nerve block . . . . . . . . . . . . 341
Upper canine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
Anterior palatine nerve block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
Upper first premolar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
Supplemental anesthetic techniques . . . . . . . . . . . . . . . . . . . . . . . . . 343
Upper second premolar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
Anesthetic solutions and inflammation . . . . . . . . . . . . . . . . . . . . . . . 343
Upper first molar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Lingual infiltration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
Upper second molar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Intraseptal injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Upper third molar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
Intraligamental infiltration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Lower central incisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
Intrapulpal infiltration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
Lower lateral incisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
Intraosseous anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Lower canine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Lower first premolar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449 Lower second premolar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452 Lower first molar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
Chapter 11
Lower second molar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Tooth isolation: the rubber dam . . . . . . . . . . . . . . . 367
Lower third molar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
Arnaldo Castellucci, Matteo Papaleoni
Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
The access cavity in prosthetically prepared teeth . . . . . . . . . . 479 The access cavity through prosthetic crowns . . . . . . . . . . . . . . . 480
Rubber dam punches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
Common errors in the preparation of the access cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482
Rubber dam clamps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
Errors related to inadequate preparation . . . . . . . . . . . . . . . . . . . . . 482
Rubber dam clamp forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Errors related to over-aggressive preparation . . . . . . . . . . . . . . . . 485
Rubber dam frame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
Rubber dam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
XVI
Table of contents
Chapter 13
Metallurgy of nickel-titanium alloys . . . . . . . . . . . . . . . . . . . . . . . . 570
Pretreatment: preparation techniques for endodontic therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Advantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572
Paolo Ferrari, Stefano Patroni
Functioning of the NiTi rotary instruments . . . . . . . . . . . . . . . . . 574 Torsional stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 574 Bending stresses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 578
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Importance of the section of the NiTi rotary instrument . . . 579
Pretreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494
Endodontic motors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581
Modern indications for endodontic pretreatment . . . . . . . . . . 495
Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583
Periodontal pretreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
Life of the NiTi rotary instrument . . . . . . . . . . . . . . . . . . . . . . . . . . . 584
Prosthetic restorative pretreatment . . . . . . . . . . . . . . . . . . . . . . . . . 497
1. Original anatomy of the canal . . . . . . . . . . . . . . . . . . . . . . . . . . . 585
Conservative restorative pretreatment . . . . . . . . . . . . . . . . . . . . . .500 Reconstruction of the fourth wall . . . . . . . . . . . . . . . . . . . . . . . . . . . 500 Pre-endodontic composite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
Orthodontic pretreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505 Chapter 14
Endodontic instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . 507 Giuseppe Cantatore, Arnaldo Castellucci, Elio Berutti
Brief history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507 Standardization of endodontic instruments . . . . . . . . . . . . . . . . 508 Hand instruments with a conventional .02 taper . . . . . . . . . . . . 514 Files . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
2. Mechanical characteristics of the selected instruments . . . . . . 587 3. Rotational speed and maximum torque values for NiTi rotary instruments . . . . . . . . . . . . . . . . . . . . . . . . 591 4. Characteristics of the work carried out . . . . . . . . . . . . . . . . . . . . 591 5. Operator ability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597
Chapter 16
Cleaning and shaping the root canal system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601 Elio Berutti, Arnaldo Castellucci
Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602 The removal of vital pulp tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
Reamers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
The removal of necrotic pulp tissue and microorganisms . . . . . . 605
Hedstroem Files . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
Irrigating solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605
Barbed Broach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524
Chelating agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
Hand instruments with greater taper . . . . . . . . . . . . . . . . . . . . . . . . 525
The dentin mud or “smear layer” . . . . . . . . . . . . . . . . . . . . . . . . . . . 623
ProFiles .04 Hand Files . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
Activation of irrigants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 631
Hand GT Files . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
Shaping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637
Micro-Openers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Mechanical objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637
®
Steel rotary instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Biological objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 649
Gates-Glidden drills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 652
Largo drills® . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528 LA Axxess™ burs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528 Endo-Eze® AET Files . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
Mechanical instruments in Nickel-Titanium . . . . . . . . . . . . . . . . 531 Mechanical instruments in Nickel‑Titanium: years 1994-2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
Chapter 17
Basic concepts for root canal shaping . . . . . . . 661 Arnaldo Castellucci, Elio Berutti
Coronal preflaring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 661 Precurvature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665
Chapter 15
Rubber stops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 666
Rotary instruments in nickel-titanium . . . . 569
Canal scouting and glide path . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 666
Elio Berutti, Giuseppe Cantatore
Patency file . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 666
Characteristics of NiTi alloy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569 Shape memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569
Determination of the instrument’s working length . . . . . . . 667 Electronic apex locators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 676
Superelasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570
New generation electronic apex locators . . . . . . . . . . . . . . . . . . . 679
Strength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570
Drying the shaped root canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 686
Table of contents
Canal preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 686 Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 686 Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687
Radiographic evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 688 Cleaning and shaping two canals of the same root . . . . . . . . . . 691 Lower molars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692
XVII
Chapter 21
ProTaper Next® and instruments with a precessional cutting axis . . . . . . . . . . . . . . . 761 Michael J. Scianamblo with illustrations by Peet Van der Vyver
Upper molars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 694
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 761
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 699
The Envelope of Motion and ProTaper Next® . . . . . . . . . . . . . . . . . . 765 The Compressibility of ProTaper Next® . . . . . . . . . . . . . . . . . . . . . . 768
ProTaper Next® Sequence and Clinical Guidelines . . . . . . . . . . . 772
Chapter 18
ProTaper Next® Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 772
Canal scouting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703
Guideline 1: complete access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 773
Elio Berutti
Guideline 2: negotiate canal to patency and create a reproducible glide path . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775
Understanding endodontic anatomy . . . . . . . . . . . . . . . . . . . . . . . . . 703
Guideline 3: ProTaper Next® preparation sequence . . . . . . . . . . . . . 776
Evaluating the amount of coronal interferences . . . . . . . . . . . . 706 Reaching the terminus of the canal . . . . . . . . . . . . . . . . . . . . . . . . . 706 Understanding when it is possible to use rotary or reciprocating NiTi instruments to both expand the Glide Path and complete the final shaping . . . . . . . . . . . 706
ProTaper Next® X2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777 Gauging of apical foramen to determine if the preparation is complete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 778 Guideline 4: shaping recommendations for ProTaper Next® X3, X4 and X5 . . . . . . . . . . . . . . . . . . . . . . . . 779 Other instruments with a precessional cutting axis . . . . . . . . . . . . 779
Operative technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 780
It is possible to reach the canal terminus without any difficulty . 708
Principles of bio-mechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 780
It is possible to reach the canal terminus but the file is stuck . . . . 709
Mass moment of inertia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 780
It is possible to reach the canal terminus but we have to rotate the file to find the patency . . . . . . . . . . . . . . . . . . . . . . . 711
ProTaper Next® file sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 782
It is impossible to immediately reach the canal terminus . . . . . . . 714
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
Instruments of critical path – Equal distribution of diameters . . . . . . . . . . . . . . . . . . . . . . . . . . . 782 Instruments of critical path – Progressive and equal diameter method . . . . . . . . . . . . . . . . . . . 784 Clinical ramifications and benefits . . . . . . . . . . . . . . . . . . . . . . . . . . 786
Chapter 19
The Glide Path and the Prelimary Enlargement
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 790 . . . . . . . . . . . . . . 721
Chapter 22
The Glide Path . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 722
ProTaper Gold®: “The Practice Transforming Magic of ProTaper Gold®” . . . 793
Preliminary enlargement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 722
John West, Clifford J. Ruddle, Pierre Machtou
Coronal preflaring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 793
PathFile™ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724
A brief history of ProTaper® . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 794
Arnaldo Castellucci, Elio Berutti, Giuseppe Cantatore
ProGlider™ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738
The ProTaper Gold® advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 795 The ProTaper Gold® clinical technique . . . . . . . . . . . . . . . . . . . . . . . . 797
Closing comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808 Chapter 20
Curved canals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741 Arnaldo Castellucci, Matteo Papaleoni
Curves of the apical third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741 Curves of the middle third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 746 Curves of the coronal third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 752 Anticurvature filing method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 755 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 759
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 809 Chapter 23
Shaping canals with confidence The WaveOne® Gold single-file reciprocating system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811 Julian Webber, Clifford J. Ruddle
From rotation to reciprocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811
XVIII
Table of contents
Controversy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 812
TRUShape® & TruNatomy™ philosophy . . . . . . . . . . . . . . . . . . . . 830
New developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 813
Design and components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 831
WaveOne® Gold system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 813
The clinical TRUShape® & TruNatomy™ technique . . . . . . . . 832
WaveOne® Gold design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 814
Summary of current research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 838
Advanced metallurgy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839
Reciprocating movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816 WaveOne® Gold protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 818 Glide Path Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 818 Single-file shaping technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
Chapter 25
The TruNatomy™ system . . . . . . . . . . . . . . . . . . . . . . . . . . 843
WaveOne® Gold advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824
Andrea Polesel
Obturating solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824
Introduction, phylosophy and rational . . . . . . . . . . . . . . . . . . . . . 843
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 825
Clinical and biological advantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 826
The indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 848 The shaping: instruments and operative protocol . . . . . . . . . . 848
Chapter 24
Root canal preparation with TRUShape® and TruNatomy™ Conforming shaping and dentin preservation . . . . . . 829
Cleansing: the key to success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850 Canal obturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 852 Clinical cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853 Clinical case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853 Clinical case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 858 Clinical case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863
Ove A. Peters, Ana Arias
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 866
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 829
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 867
Volume 2 Chapter 26
Obturation of the root canal system: biological principles, materials, and techniques . . . . . . . . . . . . . . . . . . . . . . . . 869 Arnaldo Castellucci
Medicated sealers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885 Mineral Trioxide Aggregate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885
Solid materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 887 Semi-solid materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 889 Techniques for root canal obturation with gutta-percha . . . 894 Lateral condensation of gutta‑percha . . . . . . . . . . . . . . . . . . . . . . 895
Biological considerations for root canal obturation . . . . . . . . 869
Thermoplastic gutta-percha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 900
Selecting the right time for the obturation . . . . . . . . . . . . . . . . . . . 872
Thermomechanical compaction of gutta-percha . . . . . . . . . . . 909
Apical extent of the three‑dimensional obturation . . . . . . . . . 873
Carrier based gutta-percha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 909
Cemento-dentinal junction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 873
System B technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 910
Radiographic terminus of the canal . . . . . . . . . . . . . . . . . . . . . . . . . 876
Chemical softening of gutta‑percha . . . . . . . . . . . . . . . . . . . . . . . . . 910
Overfilling and overextension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 877
Technique of warm lateral condensation: the Endotec . . . . . . 910
Properties of the obturating materials . . . . . . . . . . . . . . . . . . . . . . 882
The EndoTwinn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911
Requirements for the ideal root canal filling material . . . . . . 883
Resilon™ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 912
Endodontic pastes and cements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 884 Zinc oxide-based sealers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 884
Single-cone and EndoSequence bioceramic sealer: hydraulic condensation technique . . . . . . . . . . . . . . . . . . . . . . . . 914
Resin-based sealers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885
Operative sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 919
Paraformaldehyde cements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 919
Table of contents
XIX
Chapter 27
Sealing ability of carrier‑based obturators . . . . . . . . . . . . . . . . . . . 997
The Schilder’s technique of vertical compaction of warm gutta-percha . . . . . . . . . . . 929
Drawbacks of the carrier‑based obturation techniques . . . . . . . . 1004
Arnaldo Castellucci
Selecting the right time for the obturation . . . . . . . . . . . . . . . . . . 930
Protocol for a correct use of carrier‑based obturators . . . . . . . . 1000 Final considerations on the Carrier‑Based Obturation Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1015
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1016
Armamentarium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 930
Preparation of the tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 933
Chapter 30
Phases of obturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 934
Prefitting of pluggers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 940
System “S”: a flowable injection technique for three-dimensional obturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1019
Sealer preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 941
John Stropko
Cone fit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 935 Radiographic control of the cone fit . . . . . . . . . . . . . . . . . . . . . . . . . 939
Sealer and master cone placement . . . . . . . . . . . . . . . . . . . . . . . . . . 942 Down-packing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 942
Reverse filling (“back-packing”) . . . . . . . . . . . . . . . . . . . . . . . . . . . 949 “Back-packing” with thermoplastic gutta-percha . . . . . . . . . . . 952
Obturation of communicating and confluent root canals . . 954
Access and shaping the canal system . . . . . . . . . . . . . . . . . . . . . . . . 1020 Irrigation for cleaning the canal system . . . . . . . . . . . . . . . . . . . . .1021 Drying canals with F.I.R.E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1023 Sealer application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1024
Walter Hess work and postoperative radiographs . . . . . . . . . . . . . 958
Obturation by injection of thermo-plasticized GP . . . . . . . . . 1026
The importance of obturating lateral canals . . . . . . . . . . . . . . . . . . 959
Compaction of the warm GP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1029
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 965
Excess filling material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1029
Now for the rest of the seal to treat the entire canal system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1032 Chapter 28
An easy foundation restoration technique . . . . . . . . . . . . . . . . . . 1035
The Continuous Wave of Obturation Technique . . . . . . . . . . . . . . . . . . . . . . . . . . 967
Respect for the endo-pros relationship . . . . . . . . . . . . . . . . . . . . . 1036
L. Stephen Buchanan
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1039
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1038
Why does 3D obturation of root canal systems matter? . . . . 967 Vertical compaction of warm gutta‑percha . . . . . . . . . . . . . . . . . . 967 Electronic 3D oburation devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . 970
Chapter 31
Continuous Wave Electronic Devices . . . . . . . . . . . . . . . . . . . . . . . . . 972
Endodontic-periodontal interrelationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1041
Continuous Wave pluggers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 973
Arnaldo Castellucci
The Continuous Wave of Condensation Technique . . . . . . . . . . . . 970
CW downpack and backfill methods relative to canal size . . . . . . 974 CW downpack technique in small canals . . . . . . . . . . . . . . . . . . . . . . 975 Syringe backfilling in small canals . . . . . . . . . . . . . . . . . . . . . . . . . . . 975 Downpacking medium and large canals . . . . . . . . . . . . . . . . . . . . . 976 Single cone backfilling procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 977 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 978
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 979
Endodontic-periodontal communications . . . . . . . . . . . . . . . . . 1043 Apical foramen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1043 Lateral canals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1043 Dentinal tubules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
Etiologic classification of the endodontic and periodontal diseases of the attachment apparatus . . . . . . 1046 Primary endodontic lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
Chapter 29
Carrier-based obturation techniques . . . . . . . 981 Giuseppe Cantatore
Components of the “carrier-based” obturation system . . . . 984
Primary endodontic lesion with secondary periodontal involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1061 Primary periodontal lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1063 Primary periodontal lesion with secondary endodontic involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1067
Features of the gutta-percha used for all types of obturators . . 988
Coexisting primary endodontic and primary periodontal lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1071
Other components of the carrier‑based obturation technique . . 995
“True” combined lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1075
The obturators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 984
XX
Table of contents
Healing potential and prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1078
Chapter 34
Differential diagnosis and treatment plan . . . . . . . . . . . . . . . . . . . 1079
Root resorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1185
The influence of pulp disease on the periodontium . . . . . . . 1080 The influence of endodontic therapy on the periodontium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1085 Perforations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1087
Arnaldo Castellucci
Inflammatory resorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1186 Transient inflammatory resorption . . . . . . . . . . . . . . . . . . . . . . . . . 1186
Root fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1087
Progressive inflammatory resorption . . . . . . . . . . . . . . . . . . . . . . . 1187
The influence of periodontal disease on the endodontium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1102
Resorption with ankylosis and replacement . . . . . . . . . . . . . . . 1204
The influence of periodontal therapy on the endodontium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1104
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1221
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1110
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1223
Chapter 32
Chapter 35
The treatment of teeth with immature apices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1113
Bleaching non‑vital teeth . . . . . . . . . . . . . . . . . . . . . . . . 1227
Arnaldo Castellucci
Extracanal invasive resorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1211 Guidelines for the management of avulsed teeth . . . . . . . . . . . . . 1221
Arnaldo Castellucci
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1227
Apexogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1114
Intrinsic genetic discolorations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1227
Apexogenesis with calcium hydroxide . . . . . . . . . . . . . . . . . . . . . . 1118
Intrinsic metabolic discolorations . . . . . . . . . . . . . . . . . . . . . . . . . . 1228
Apexogenesis with Mineral Trioxide Aggregate . . . . . . . . . . . . . . . 1123
Intrinsic medicine-related discolorations . . . . . . . . . . . . . . . . . . . 1228
Apexification with Calcium Hydroxyde . . . . . . . . . . . . . . . . . . . . . 1126 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1128
Causes of pigmentation of pulpless or endodontically treated teeth . . . . . . . . . . . . . . . . . . . . . . . . . . 1230
Types of apical closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1130
Pulpal hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1230
Histology of the apical barrier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1136
Decomposition of pulp tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1232
The role of calcium hydroxide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1137
Intracanal medicaments and sealers . . . . . . . . . . . . . . . . . . . . . . . . 1235
Techniques of obturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1138
Restorative materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1240
Apical barrier technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1138
Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1243
A new possibility of treatment for immature permanent teeth with apical periodontitis . . . . . . . . . . . . . . . . . . . . . . . . . . . 1151
Bleaching agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1243 Hydrogen peroxide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1243
Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1151
Carbamide peroxide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1244
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1152
Sodium perborate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1244 Bleaching mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1244
Preparation of the tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1244 Chapter 33
The concept of pulp regeneration in endodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1159 Mario Alovisi
The treatment of necrotic permanent teeth with an immature apex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1159 Regeneration or revascularization . . . . . . . . . . . . . . . . . . . . . . . . . . . 1165 The biological components of pulp regeneration . . . . . . . . . . . . . . 1168 Clinical procedure for the regeneration of the pulp . . . . . . . . . . . 1170 Example of the clinical protocol for the pulp regeneration procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1173 Clinical outcomes of pulp regeneration treatment . . . . . . . . . . . . 1178
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1180
Bleaching methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1251 Walking bleach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1251 Thermocatalytic technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1253
Final obturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1254 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1255 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1256 Guidelines for the prevention of discoloration . . . . . . . . . . . . . 1259 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1260
Table of contents
Chapter 36
The use of the operating microscope in Endodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1263 Arnaldo Castellucci, Matteo Papaleoni
XXI
Gaining access to the canal terminus . . . . . . . . . . . . . . . . . . . . . . . . 1331 Removal of filling materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1331 Gutta-percha removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1332
Broken instrument removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1351 Factors influencing broken instrument removal . . . . . . . . . . . . . . 1353
Introduction to the operating microscope . . . . . . . . . . . . . . . . . . 1263
Coronal and radicular access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1356
The limits of human vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1264
Creating a staging platform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1356
Why enhanced vision is necessary in dentistry . . . . . . . . . . . . . . . 1266
Techniques for removing broken instruments . . . . . . . . . . . . . . . . 1357
Optical principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1266
Broken instrument prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1364
Magnification. Loupes and microscope . . . . . . . . . . . . . . . . . . . . . . 1267
Blocks, ledges & apical transportations . . . . . . . . . . . . . . . . . . . . . 1364
Anatomy of the surgical operating microscope . . . . . . . . . . . . . . . 1269
Techniques for managing blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1365
Positioning the microscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1281
Techniques for managing ledges . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1366
Ergonomics and the microscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1288
Techniques for managing apical transportations . . . . . . . . . . . . . 1369
The use of the operating microscope in Endodontics . . . . . . 1288
Endodontic perforations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1374
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1288
Missed canals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1374
Locating the canal orifices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1290
Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1374
Retreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1294
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1375
Learning curve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1294
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1295 The future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1295
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1295
Chapter 37
Nonsurgical endodontic retreatment . . . . . . 1297 Clifford J. Ruddle, Pierre Machtou, Arnaldo Castellucci
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1297 Retreatment definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1298 Retreatment vs. initial treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 1299 Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1300 Rationale for retreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1300 Criteria for success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1302 Decision making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1303
Nonsurgical vs. surgical retreatment . . . . . . . . . . . . . . . . . . . . . . . 1307 Factors influencing retreatment decisions . . . . . . . . . . . . . . . . . . . 1309
Clinical procedures and sequencing dissassembly . . . . . . . . . . 1312 Gaining access to the root canal/coronal disassembly . . . . . . 1312
Chapter 38
Iatrogenic events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1381 Laura Garcia Aguilar, Elio Berutti, Giuseppe Cantatore, Arnaldo Castellucci, Pierre Machtou, Clifford J. Ruddle, Filippo Santarcangelo, Yoshi Terauchi
Section I – Missed anatomy: frequency and clinical impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1381 Giuseppe Cantatore, Elio Berutti, Arnaldo Castellucci, Clifford J. Ruddle, Pierre Machtou
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1381 Rational of endodontic therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1382
Risk of missing canals in maxillary teeth . . . . . . . . . . . . . . . . . . . 1383 Recommended clinical approach in maxillary molars . . . . . . . . . 1386
Risk of missing canals in mandibular teeth . . . . . . . . . . . . . . . . . 1386 Risk of missing lateral canals in maxillary and mandibular teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1390 Prevention of missed anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1390 Knowledge of root canal anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 1390
Factors influencing restorative removal . . . . . . . . . . . . . . . . . . . . . 1313
Radiographic examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1390
Coronal disassembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1314
Access opening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1392
Post removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1319
Use of operating microscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1393
Factors influencing post removal . . . . . . . . . . . . . . . . . . . . . . . . . . . 1319
Use of ultrasonics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1394
Techniques for access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1321
Armamentarium and techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1396
Techniques for post removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1322 Mechanical option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1324
Impact of missed anatomy on the outcome of endodontic treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1399
Special circumstances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1327
Concluding remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1399
Inadvertent tap “pop-off” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1327 Avoiding post “shear-off” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1329 Using the PRS on anterior teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1329
Removal of a fiber post . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1330
Section II – Management of instrument fracture . . . . . . . 1400 Yoshi Terauchi
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1400
XXII
Table of contents
Etiology of instrument fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1400
Medical considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1488
How an instrument fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1400
Past medical history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1488
Management of separated instruments . . . . . . . . . . . . . . . . . . . . . 1402
Antibiotic medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1490
Conditions for separated instrument removal attempts . . . . . . . . 1414
Anti-inflammatory medications . . . . . . . . . . . . . . . . . . . . . . . . . . . 1490
Separated instrument removal preparation . . . . . . . . . . . . . . . . . . 1415
Psychological considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1490
Separated instrument removal attempts . . . . . . . . . . . . . . . . . . . . . 1418 Case selection for separated instrument removal . . . . . . . . . . . . . 1425 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1435 Potential complications of separated instrument removal . . . . . 1436
Section III – Repair of iatrogenic endodontic perforations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1439 Arnaldo Castellucci, Pierre Machtou, Clifford J. Ruddle
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1439
Preparation of the surgical team, instruments, and equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1491 The surgical team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1491 Preparation of the instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1492 Par-focal adjustment for the microscope . . . . . . . . . . . . . . . . . . . . 1496
Preparation of the patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1497
Patient considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1497
Considerations influencing perforation repair . . . . . . . . . . . . . . . . 1439
Anesthesia and hemostasis staging . . . . . . . . . . . . . . . . . . . . . . . 1500
Periodontal condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1440
Local anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1500
Materials utilized in perforation repair . . . . . . . . . . . . . . . . . . . . . . 1443 Treatment sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1450 Techniques for repairing perforations . . . . . . . . . . . . . . . . . . . . . . . 1454
Hemostasis staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1502 Toilet and stabilization of the surgical site . . . . . . . . . . . . . . . . . . . . 1504
Management of perforations in the apical one-third . . . . . . . . . . 1458
The incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1505
The repair of perforations using a new bioceramic material . . . . 1461
Anatomical considerations for incisions . . . . . . . . . . . . . . . . . . . . 1505
Criteria for assessing success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1462
Inferior alveolar nerve (mandibular nerve) . . . . . . . . . . . . . . . . . . . 1505
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1462
Mental nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1505
Section IV – The sodium hypochlorite accident
. . . . . . . . 1463
Filippo Santarcangelo, Laura Garcia Aguilar
The disinfection challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1463 Classical mid-face ecchymotic appearance . . . . . . . . . . . . . . . . . . . 1463
Intravenous injection theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1464 Biophysics of intravenous injection via the root canal system . . 1465 Confirmation of the intravenous injection theory . . . . . . . . . . . . 1466
Greater palatine artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1506 Incision types & considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1506 Surgical flap types & considerations . . . . . . . . . . . . . . . . . . . . . . . . . 1509
Atraumatic flap elevation and tissue retraction . . . . . . . . . 1514 Reflection of the flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1514 Atraumatic flap retraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1516
Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1467
Access, Root End Resection (RER), and crypt management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1518
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1468
Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1518
Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1468
Crypt management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1521
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1468
Ferric sulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1522
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1469
Calcium sulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1524
Root-End Bevel (REB), Root-End Preparation (REP) . . . . Chapter 39
Microsurgical endodontics . . . . . . . . . . . . . . . . . . . . . . 1479 John J. Stropko
1527
The Root-End Bevel (REB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1527 Methylene blue staining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1529 Ultrasonic root end preparation (REP) . . . . . . . . . . . . . . . . . . . . . . . 1531
Root End Filling (REF) Techniques and Materials . . . . . . . 1538
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1479
Root End Filling Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1538
Endodontic surgery or surgical Endodontics? . . . . . . . . . . . . . . 1479
Amalgam and IRM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1538
Microscopes, endoscopes, and computer assisted technology for enhanced vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1481
SuperEBA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1538
Indications for surgical Endodontics . . . . . . . . . . . . . . . . . . . . . . . . 1482 Contraindications for surgical Endodontics . . . . . . . . . . . . . . . . . . 1483
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1486
Bonding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1541 Mineral Trioxide Aggregate (MTA) . . . . . . . . . . . . . . . . . . . . . . . . . . 1543 EndoSequence® Bioceramic Root Repair Material™ (BC-RRM) . 1547
Clinical findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1486
Sutures and suturing techniques . . . . . . . . . . . . . . . . . . . . . . . . . 1550
Radiographic tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1486
Closure of the surgical flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1550
Table of contents
XXIII
Suturing technique using the SOM . . . . . . . . . . . . . . . . . . . . . . . . . . 1552
Chapter 40
Suturing considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1558
Restoration of the endodontically treated tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1577
Postsuturing management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1558 Using lasers for biostimulation, or postsurgical photobiomodulation (PBM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1559 24 hour suture removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1561
Nicola Scotti
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1577
Healing and postoperative care . . . . . . . . . . . . . . . . . . . . . . . . . . . 1563
The coronal seal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1579
Postoperative care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1563
Cusp fracture of an endodontically treated tooth . . . . . . . . . . . . . 1579
Postsurgical home care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1563
Cusp coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1580
Optional micro-surgical endodontic procedures . . . . . . . 1564 Presurgical restorations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1564
The limits of adhesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1584 Fiber posts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1586 Decisional criteria for choosing a postendodontic restoration . . 1587
Presurgical restoration prior to root amputation . . . . . . . . . . . . . 1564
Direct restorations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1588
Presurgical placement of root‑end fill (REF) prior to apicoectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1564
Indirect adhesive restorations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1596
Presurgical REF using MTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1565 Presurgical REF using BC-RRM, or MTAFLOW . . . . . . . . . . . . . . . 1566
The full crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1608
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1608
Trans-antral approach for apical surgery (TAA) . . . . . . . . . . . . . . 1566
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1572 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1572
Index
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1613
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The Schilder’s technique of vertical compaction of warm gutta-percha Arnaldo Castellucci
Many endodontists are convinced that they must be familiar with several techniques of canal obturation, since each technique is indicated in certain situations, but not others. Nguyen Thanh Nguyen1 is of this opinion. He states: “to be married only to one obturation technique or material is to limit one’s ability to undertake a diversity of complex cases”. Frank, Simon, Abou-Rass, and Glick2 are also strongly convinced that there can be no single, rigid obturation technique that can meet all endodontic needs. Franklin Weine3 takes the same view. He discusses the various techniques of gutta-percha use, emphasizing that vertical compaction is to be preferred in certain, well-defined cases, namely “when the fitting of a conventional master cone to the apical portion of a canal is impossible, as when there is a ledge formation, perforation, or unusual canal curvatures, internal resorptions, or large lateral canals. The vertical compaction method then affords the
operator a chance to achieve success in a case that might fail if any other kind of treatment were used”. It is interesting to note that those who share these opinions have adopted the “lateral condensation technique,” yet to achieve success even in difficult cases, feel the need to make use of techniques which require heat softening and vertical compaction. The converse does not occur: those who are conversant with the technique of vertical compaction never need to resort to the lateral condensation technique to resolve easy cases... The vertical compaction technique of warm gutta-percha, conceived and described by Schilder4 in 1967, combines a reasonable ease of execution with maximal efficacy in obturating both simple and more complex canals.5 Just as one vertically compacts the plastic amalgam within a class-one cavity, gutta-percha softened by heat is vertically compacted into the conically shaped canal preparation which is nothing else than a narrow and deep class-one cavity.
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Selecting the right time for the obturation As already stated in Chapter 26, once cleaning and shaping of the root canal system has been completed, the clinician may proceed to the obturation procedure when the following requirements are met: Ä The tooth is asymptomatic. There is no pain on apical palpation or on percussion, and the patient feels perfectly comfortable. Ä The canal must be dry or, at any rate, easily dried with absorbent sterile paper points. This is a condicio sine qua non for proceeding to obturation. Ä There must be no fistula. If one was not present before, it must not have developed in the interim; if one was present at the beginning of treatment, it must have completely resolved. Ä There must be no foul odor, indicating the presence of bacteria that have either persisted in the canals or have entered because of inadequate sealing of the temporary cement. Ä If the root canal has been shaped in a previous visit, the temporary cement must be intact. If compromised, is a certain sign of canal contamination.
Armamentarium PLUGGERS The instruments used for compacting the gutta-percha in this technique are similar to amalgam compactors. How-
! 27.1 A plugger of the “Posterior” series, for teeth of 25 mm or less (left). A plugger of the “Anterior” series, for teeth of 30 mm (right) (Dentsply Sirona, USA).
ever, they differ from them by being longer and narrower, since the cavity in which they work is longer and thinner. These instruments are referred to as compactors or “pluggers” (! 27.1). Serrations at 5 millimeter intervals help to assess the working depth each instrument specifically made to prevent it coming into contact with the dentin. In contrast to the lateral condensation technique, in which the spreaders touch the dentinal walls in order to make space for the auxiliary cones, in vertical compaction the metal instruments never touch the canal walls, but are only sunk into the mass of previously heated gutta-percha. Particularly useful are the double ended pluggers: one end is in NiTi, smaller and flexible, and the other end is stainless steel, larger and rigid, like the ones manufactured by Obtura Spartan, USA, (0.80, 1.00, and 1.20 mm in the stainless steel end and 0.40, 0.50, and 0.60 in the NiTi end) and by B&L (Bio Tech, Korea) (0.70, 0.80, 1.00, and 1.20 mm in the stainless steel end and 0.35, 0.40, 0.50, and 0.60 in the NiTi end) (! 27.2).
HEAT CARRIER The other instrument that this technique requires is the “heat carrier,” that is used to deliver heat to the gutta-percha cone in the root canal. Several types of heat carriers are available, like the Touch ’n Heat™ (SybronEndo, USA), the Elements™ (SybronEndo, USA), the Calamus® (Dentsply Sirona, USA), or the new cordless Alpha 2 from B&L (Bio Tech, Korea) (! 27.3). These instruments are provided with tips of different tip diameter and different taper (! 27.4).
! 27.2 The three most frequently used pluggers from B&L (B&L Bio Tech, Seoul, Korea).
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b
a
c
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d
! 27.3 a) The “Touch ’n Heat™” heat carrier by SybronEndo, USA. b) The “Alpha 2” heat carrier from B&L (B&L Bio Tech, Seoul, Korea). c) The Elements™ Obturation Unit (SybronEndo, USA). d) The Calamus® (Dentsply Sirona, USA).
! 27.4 B&L tips (B&L Bio Tech, Seoul, Korea) of different sizes and tapers, to be used both in Schilder’s technique and in the Continuous Wave of condensation.
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GUTTA-PERCHA CONES The gutta-percha cones indicated for this technique are tapered. Although they have the same chemical composition as the standardized ones, they are more conical and thus provide a larger amount of gutta-percha on which to exert vertical force with the working surface of the pluggers. In the original Schilder technique the sizes most commonly used were “fine,” “fine-medium,” “medium,” and “medium large” (! 27.5). Today, many shaping NiTi systems are available each having gutta-percha points that correspond to its shaping files (! 27.6).
SEALER A minimal amount of sealer is necessary to ensure better adaptation of gutta-percha to the canal walls. It has
already been explained that the sealer represents the weakest part of the filling material, which therefore must be entrusted as much as possible to the gutta-percha. For this reason, the ideal sealer for this technique is the one which can be spread onto the canal walls as a microfilm a few microns in thickness.5,6 Many of the endodontic sealers commercially available can be used, as long as they meet these requirements: they must be inert, biocompatible (or at least well tolerated by the tissues), non-shrinking, and non-resorbable. A study by Weiner and Schilder7 found that there is a strict relationship among the sealer’s setting time, its resorbability, and its shrinkability: the longer the setting time, the easier the sealer will shrink and be resorbed. Sealers that appear to be the least affected are the Pulp Canal Sealer™ (Kerr, USA), that has a relatively short setting time (! 27.7a), and the Pulp Canal Sealer EWT™ (Kerr, USA), that allows an easier manipulation due to its extended working time (! 27.7b). The composition of this sealer, in Rickert’s 1931 formulation, is:8
Powder Ä Silver 24.74% Ä Zinc oxide 34% Ä Thymol iodide 10.55% Ä Oleoresin 30.71%
Liquid ! 27.5 Non-standardized gutta-percha cones used with vertical condensation of warm gutta-percha.
Ä Eugenol 78% Ä Balsam of Canada 22%
! 27.6 Gutta-percha cones, used after shaping the root canal with rotary systems, such as ProTaper Next®, ProTaper Gold®, TruNatomy™ or with reciprocating systems such as WaveOne® Gold.
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a
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b
! 27.7 The Pulp Canal Sealer™ (Kerr) (a) and the Pulp Canal Sealer EWT™ (Kerr) (b) are best suited for the Schilder technique.
Preparation of the tray Before proceeding with obturation, the dental tray must have: Ä The complete series of pluggers, to which rubber stops have been attached for ease of use and better control of the working depth.
Ä Several packages of sterile absorbent paper points. Ä A locking-pliers to handle the gutta-percha cones. Ä Film holder with the intraoperative radiograph already positioned. Ä A mirror having a millimeter scale on the handle. Ä An endodontic probe JW17.
Ä A dappen dish containing sodium hypochlorite in which several cones of the sizes felt to be necessary are sterilized for at least one minute.
Ä A pair of scissors in case it is necessary to remove the tip of the gutta-percha cones.
Ä The syringes full of irrigating solutions for the final irrigation.
The dentist must also have within reach:
Ä A pure-alcohol-moistened sponge into which the assistant places the last instruments at the working length of the canals of the tooth in question (preferably a NiTi hand file of the size correspondent to the diameter of the foramen). The assistant must make certain to position them just as the canal openings appear in the pulp chamber (! 27.8a, b ).
Ä A small glass plate and a sterile spatula with the powder and liquid of the sealer. Ä Boxes of gutta-percha cones of the required size. The assistant must have access to: Ä The handpiece of the electric heat carrier. Ä The Beta 2 syringe.
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a
b
c
d
! 27.8 a) In a sponge moistened with pure alcohol, the assistant positions the NiTi file of each canal (correspondent to the size of each foramen), reproducing the topography that the endodontist sees when he examined the pulp chamber with the dental mirror. The instruments in the photograph are positioned to obturate the canals of an upper right molar with four canals. b) The instruments in the photograph are positioned to obturate the canals of a lower right first molar. c) If the obturation is going to be made in another visit, the instruments of the patient are stored and will be sterilized and used later, when the canals will be ready for filling. d) The organizer holding PathFiles® and ProTaper Next® and the Ergo by Style Italiano holding the Nitiflex of each canal.
Phases of obturation The rubber dam is applied, positioning the same clamp used in the cleaning and shaping phase, (whose number should have been recorded in the chart and which has been stored together with the instruments used for that particular tooth of that particular patient) in case of a two-visit procedure. If the temporary medication was sealed with Cavit, it is removed with the help of an ultrasonic tip. If IRM or another, more resistant cement was used, it will be necessary to remove it with a high-speed bur. The temporary medication – a cotton pellet with a
dab of Cresatin – is removed from the pulp chamber, and the canals are washed with sodium hypochlorite to remove any exudate that may have accumulated in the root canals. With the last instrument at the terminus of each canal, the patency and the size of the apical foramen is checked and the endodontic anatomy is reviewed, after which it is irrigated again with sodium hypochlorite, EDTA, and alcohol, which the assistant then aspirates from the pulp chamber with a surgical aspirator. Using sterile absorbent paper points (measured by the assistant with a tweezers at the exact working length) (! 27.9) and the Stropko irrigator (! 27.10) using the
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! 27.9 The paper points are measured by the assistant with a tweezers at the exact working length.
! 27.10 The Stropko irrigator.
minimum air pressure, the root canals are completely dried so as to remove any trace of moisture. A final check of the apical patency is then made, and then the gutta-percha cone is prepared.
As mentioned in Chapter 16, in accordance with the second mechanical objective of shaping described by Schilder,9 the apical cross-sectional diameters of the prepared root canal must diminish corono-apically. As a consequence, the cross-sectional diameter of the shortened gutta-percha point is bigger than the cross-sectional diameter of the foramen. When one begins to compact and push the cone vertically, the cone moves apically, and its tip will become engaged in progressively smaller portions of canal. This will lead to deformation of the cone ensuring a good seal and a good apical control of the obturating material. On the other hand, if the gutta-percha cones are not shortened, they will protrude beyond the apical foramen as a result of the vertical force until its cross-section is almost equal to, if not greater than, the diameter of the apical foramen. The tip of the gutta-percha cone is shortened by using a special gauge (! 27.13) or small scissors and selectively removing varying amounts of the apical tip until it enters the canal comfortably and binds. This must occur at the working length and the depth is marked on the cone with a notch made by cotton pliers at the reference point of the stop. The fit is initially checked by comparing the length of the cone with that of the last instrument at the terminus of the respective canal (! 27.14), followed by a control radiograph. As already mentioned, apart from being slightly shorter than the last apical file, it should exhibit certain retention or “tug-back” within the canal. The cone must
Cone fit If feathered gutta-percha cones are used, they must be slightly shortened (! 27.11) up to the size of the apical foramen, and a radiograph taken to check the cone fit. The gutta-percha point should reach the working length and show to have retention inside the root canal (tugback). After the appropriate cone fit has been confirmed on the radiograph, the tip of the cone is cut so as to be slightly short with respect to the preparation (! 27.12).
! 27.11 The feathered gutta-percha cone just removed from its wrapper must always be blunted with a pair of scissors.
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a
Notch b ! 27.12 After the radiographic control of the cone fit, the cone must be slightly shorter than the preparation. A notch is made by cotton pliers at the level of the reference point.
! 27.13 a, b) The gutta-percha cone is cut off using a special gauge (Dentsply Sirona, USA) for gutta-percha points. This gauge is very useful to cut off the gutta-percha cones to the desired diameter.
! 27.14 The relation between the gutta-percha cone and the reference instrument (NiTiflex file correspondent to the diameter of the foramen) informs the operator how short the cone is relative to the canal preparation.
The Schilder’s technique of vertical compaction of warm gutta-percha
How much must the cone be shortened with respect to the canal preparation? The cone must be shortened by the length, by which one expects that it will rise during the compaction phase. In other words, in wide, straight root canals, where pluggers descend easily in the apical portion and where it will therefore
a
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be easy to move the gutta-percha apically, it is better to shorten it more, by at least 1-2 mm (! 27.15). In contrast, in narrower, more curved canals, in which the pluggers descend less and it will be more difficult to move the gutta-percha apically, one must shorten the cone by only a few fractions of a millimeter, so as not to risk a short obturation (! 27.16).
not be loose in the root canal, but must bind apically and oppose a certain resistance to withdrawal: this is an index of retention, which opposes the cone’s removal from the root canal when heated with the heat carrier. At this point, two questions may arise:
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How does one know whether the “tug-back” of the cone is due to the binding in the most apical portion or to binding laterally, somewhere short of the apical foramen? Obviously, if one is confronted by the
! 27.15 a) Intraoperative radiograph of the cone fit in an upper central incisor: the canal is wide and straight; therefore, the cone is shortened by about 2 mm. b) Postoperative radiograph: during the vertical compaction, the cone has moved to the end of the preparation. A lateral canal has been filled, with a good apical control of the obturating material.
b
b
! 27.16 a) Intraoperative radiograph of the cone fit in a lower third molar: the canals are narrow and slightly curved; therefore, the cones are shortened by a fraction of a millimeter. b) Postoperative radiograph.
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b
e
c
! 27.17 a) On the left the Medium (.08 taper) cone and on the right the Fine-Medium (.06 taper) cone: they both reach the working length and they both have a good tug back: which one should we select? Note that the cone on the right has more cut off. b) The two cones at higher magnification. c) The tip of the Medium cone as seen at 64x magnifications. d) The tip of the Fine-Medium cone as seen at 64x magnifications: the tip diameter is bigger and the cone presents some streakings in the apical few millimeters, because it was in contact (tug back) with the dentinal walls. Those streakings are not evident on the Medium cone. It is obvious, therefore, that the right cone to be used is the one with less taper (Fine-Medium), which has an apical tug back and a larger diameter tip. e) The coronal site of the tug back of the Medium cone is evident.
The Schilder’s technique of vertical compaction of warm gutta-percha
latter situation and the tip of the cone is of lesser diameter than the apical foramen, once the friction is overcome in the compaction phase the cone will be pushed beyond the apex and will stop only when its body is entrapped by the apical foramen. It is therefore necessary to determine the site of the “tugback”. This can be done by taking another cone of smaller size (less tapered) and gradually shortening it until it also exhibits tug-back. The lengths of the two cones (the first more tapered, for example a medium or .08 taper), the second thinner, for example a fine-medium or .06 taper) are then compared. If the two lengths are identical but the .08 taper cone has a smaller diameter as compared to the .06 taper cone (! 27.17), this means that the .08 taper cone has a lateral, instead of apical, tug-back. In summary, the gutta-percha cone must be shortened so that its apical diameter is of the same size as the apical foramen. For this purpose, the instrument designed by Maillefer and shown in Fig. 27.13 is very useful. The cone should now be fitted to the working length, should have adequate tug back and should be checked radiographically: then, after being shortened about half a millimeter, it is ready for obturation. If the canal was prepared using NiTi instruments systems like ProTaper Gold®, ProTaper Next®, WaveOne® Gold, TruNatomyTM, TRUShape®, and similar ones, the cone fit is much easier and the clinician will choose the
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cone corresponding to the taper prepared in the root canal (see ! 27.6). However, the principles are exactly the same: the cone should have an adequate tug-back, should fit slightly short of the working length, and should then reach the apical foramen during compaction, to assure an adequate apical seal of the root canal system.
Radiographic control of the cone fit When the cone has been shown to descend to the desired depth and to have sufficient tug-back, it is reinserted into the canal and a radiograph is obtained. One should not proceed to obturation if the radiograph does not give precise information regarding the position of the cone. Following the radiographic control of the cone, which has been notched with the cotton pliers at the reference point, it is shortened about half a millimeter, then it is placed on the sponge next to the last apical file of the respective canal (! 27.18) and everything is ready for obturation. It is very important to make the radiographic check before shortening the gutta-percha cone, so as to confirm that the tip of the cone is at the right working length, the radiographic terminus of the canal. Only after the radiographic check the cone is shortened, and later in the postoperative radiograph the cone should be back to the previous depth, to confirm that it moved apically to engage the foramen.
b
! 27.18 After radiographic verification of the cone fit, the cones are removed from the root canals and placed on the sponge, each next to the apical files of the respective canal. a) Cones for an upper right first molar. b) Cones for a lower molar.
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Prefitting of pluggers The pluggers must be prefitted into the canal to determine the depth to which they can be introduced without touching the dentin walls. The essence of the technique is to capture the maximal cushion of softened gutta-percha and to compact it vertically.10 Starting with a sufficiently wide plugger, that descends in the coronal one third of the canal (e.g., a Maillefer # 10 or a blue B&L, Bio Tech, Korea) and advancing to smaller sizes. If the plugger has been supplied with a rubber stop, the instrument is introduced into the canal and the stop is positioned just before the instrument touches the dentinal walls (! 27.19a). Next, a second plugger (e.g., a # 9 or yellow B&L, Bio Tech, Korea) is selected, that descends into the middle one third, again adjusting its rubber stop
a
b
(! 27.19b). Finally, a third, narrower plugger, that descends into the apical one third is advanced to a point about 5 mm from the apical foramen (e.g., a # 8 or 81/2 or a black B&L, Bio Tech, Korea), and its stop is also adjusted (! 27.19c). If the clinician used a plugger of smaller size to compact a wide surface of gutta-percha, the instrument would sink into the heat-softened material without exerting any pressure (! 27.20). In contrast, a wide plugger captures the largest amount of gutta-percha, compacting it not only apically but also, without any force, laterally (! 27.21). The pluggers must never touch the dentin walls, since by doing so it will no longer exert any pressure on the gutta-percha for compaction purposes, while potentially causing damage (e.g. crack or root fracture) by their wedging action.
c
! 27.19 a) Prefitting the first plugger in the coronal one third. The rubber stop is positioned immediately before the tip of the instrument makes contact with the dentin walls. b) Prefitting the second plugger in the middle one third. c) Prefitting the smallest plugger. Its working depth is about 5 mm from the apical foramen.
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! 27.20 The small plugger used in a wide section of the root canal does not compact at all but simply sinks into the heat-softened gutta-percha.
! 27.21 To be effective, the plugger must capture the maximum cushion of warm gutta-percha. Thus, its size must always be proportionate to the section of the canal where it is working.
Sealer preparation
advisable to prepare some extra amount of powder on a glass slab and two drops of liquid (! 27.22). At least twothirds of the powder is dissolved in one drop of liquid to obtain a uniform, creamy mixture. Freshly-prepared sealer must be viscous enough to exhibit at least a 10 cm of “string” (! 27.23). The powder remaining on the glass slab can be applied to the tip of the plugger to prevent the heat-softened gutta-percha cone from adhering to it. This reduces the risk of the gutta-percha being pulled out the root canal during the process. The second drop of liquid can be used just in case the mixture by mistake is too dense.
It has already been stated that the sealers of choice for this technique is Pulp Canal Sealer™ EWT (Kerr, USA) since it best meets the requirements discussed above. Commercially, the Extended Working Time Kerr Sealer comes in a bottle of powder and a bottle of liquid and it should be prepared according to the manufacturer’s instructions. A study by Casanova11 demonstrated that an increase of the powder/liquid ratio diminishes the solubility and resorbability of the sealer without affecting its fluidity and thus its capacity to spread as a microfilm. It is therefore
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The Schilder’s technique of vertical compaction of warm gutta-percha
Sealer and master cone placement
! 27.22 On a sterile glass slab, a small amount of powder and two drops of liquid (one of which is kept in reserve) are prepared by the dental assistant. It is then mixed by the endodontist to achieve the desired consistency.
The cone, which after the radiographic control was shortened and placed on the alcohol-moistened sponge, is dried with a sterile gauze and then the entire length which will enter in the root canal is coated with a thin layer of sealer (! 27.24). The cone is then placed in the canal orifice and, with gentle pushes, made to slide slowly and carefully to the maximal depth designated by the notch. The slow, careful introduction of the cone into the canal causes the air and any excess sealer apical to the cone to exit laterally and coronally, without creating any increased pressure or issuance of sealer into the periapical area. If in its coronal third the canal has a particularly elliptical shape, an auxiliary cone is introduced alongside the cone just introduced (! 27.25). This is not so much to condense it laterally to the first one, as to have a greater mass of gutta-percha to compact apically.
Down-packing
! 27.23 Properly prepared sealer must not “drip” but make at least an 8-10 cm “string”.
! 27.24 The entire surface of the cone entering the root canal is coated with a thin layer of sealer.
The vertical compaction of warm gutta-percha here described is performed with four hands. The assistant hands the heat-carrier to remove the excessive portion of gutta-percha extruding in the pulp chamber (! 27.26). The heat-carrier is returned to the assistant, who at the same time hands the wider prefitted plugger (after having powdered its tip with sealer powder to prevent adhesion to the tacky gutta-percha) to begin the vertical compaction (! 27.27). The plugger is then returned, while the heat-carrier is handed back. This is introduced cold in contact with the coronal portion of gutta-percha and then is activated and gently pushed apically for 3-4 mm into the gutta-percha mass (without touching the dentin walls), where it remains for a fraction of a second (! 27.28).10 The heat-activating element is then deactivated and released after a quick short pause. The cooling instrument is then removed, along with an adhered bite of gutta-percha (! 27.29). In this manner, the gutta-percha is heated around the heat-carrier and about 3-4 mm apically (no more, because gutta-percha is not a conductor of heat).12 When the instrument is withdrawn from the root canal, simultaneously a bite of gutta-percha has remained attached to it and is then removed.
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Chapter 27
! 27.25 In very wide or elliptical canals, it is advisable to introduce a supplemental cone(s) alongside the master cone for added bulk of gutta-percha to be compacted apically.
! 27.26 The gutta-percha that protrudes into the pulp chamber is seared off with a heat carrier.
! 27.27 The first plugger (whose tip is powdered with leftover sealer so the gutta-percha cone does not attach to it) initiates the vertical compaction of the gutta-percha just heated by the preceding heat carrier.
! 27.28 The heat-carrier is introduced into the center of the gutta-percha cone in the root canal.
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The Schilder’s technique of vertical compaction of warm gutta-percha
! 27.29 The heat-carrier is heating the gutta-percha apically to its tip and removes the surrounding material from the canal.
! 27.30 The heat-carrier is withdrawn, carrying out the cooled gutta-percha around it. This way, the level of the next compaction will be more apical.
The heat-carrier is returned to the assistant, who cleans it of all traces of gutta-percha (! 27.30). and simultaneously hands the pre-fitted plugger which is now used to compact and push apically the gutta-percha that has just been heated in the root canal (! 27.31). We always begin with the widest prefitted plugger, since as already suggested, we want to capture the maximum cushion of softened gutta-percha with appropriate pluggers and to gradually move the entrapped material toward the apex.5 If we begin with a narrower plugger, it would penetrate the gutta-percha softened by the heat-carrier, without exerting any pressure and without compacting it effectively (see ! 27.20). The force exerted by the plugger should be delicate but sustained and firm. Excessive force is not required. The work is generated by the wrist, not the elbow, and certainly not the shoulder. If, after having given the first stroke to the central mass of the cone, we sense that the plugger is sinking into the gutta-percha and leaving traces laterally, we must attempt with light strokes to direct the traces of gutta-percha left on the walls toward the center of the root canal. In this way, the working level is kept relatively flat and homogeneous; this ensures good compaction of the mass. The plugger is then returned to the assistant, who hands back the heat-carrier. The heat carrier is again introduced into the canal to a depth of 3-4 mm and is removed once again covered with remnants of gutta-percha (! 27.32) and the same prefitted plugger is used to compact the softened gutta-percha apically as well as laterally. It is important that each time the heat-carrier enters the canal, becomes hot enough to transfer heat to the gutta-percha mass, and that after a short hesitation it is withdrawn relatively quickly, to prevent the gutta-percha from “freezing” on the instrument, which would cause inadvertent removal of the entire gutta-percha cone at an early stage of the compaction process. Once compaction has proceeded more deeply into the canal, it is impossible to remove the gutta-percha involuntarily in this way.5 The cyclic use of heat carrier and pluggers continues until the smallest plugger arrives to compact the material at about 5 mm from the working length. As already stated, the heat carrier is introduced cold inside the root canal, in contact with the coronal mass of gutta-percha, then is activated and gently pushed apically 3-4 mm.
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! 27.31 The first plugger repeats and completes the vertical compaction process in the coronal third of the root. Once the rubber stop is approaching the reference point, it is time to select a plugger of slightly smaller diameter.
! 27.32 The heat-carrier is returned and is activated for just one second once it makes contact with the gutta-percha inside the root canal. It is then inserted directly into the central portion of the gutta-percha mass to a depth of 3-4 mm and quickly inactivated and withdrawn while cooling, removing another piece of gutta-percha from the root canal.
Then is deactivated, it cools, and the surrounding gutta-percha remains “frozen” and attached to the instrument while is cooling. Removing the tip from the root canal at the same time each time part of the gutta-percha is removed, so that the level of compaction moves more and more apically. The prefitted plugger will continue to be used until the rubber stop indicates that it is coming in contact with the dentin walls. At this point, the assistant will hand the heat carrier and then the plugger of smaller size, which will continue to compact the heated gutta-percha until it also reaches the maximal limit of its working depth (! 27.33). A new introduction of the heat-carrier (! 27.34) will then remove another bite of gutta-percha (! 27.35), moving more apically the level of compaction. Now the assistant will hand the smallest plugger, to compact the softened material in the most apical portion of the root canal (! 27.36).
What is happening now within the root canal during this cyclic use of the heat-carrier and pluggers? Three very important things:5
1
From the very beginning, the force is exerted in a “closed” space where a significant hydraulic effect is produced. Coronally, the plugger of adequate size exerts its pressure against the maximal amount of heat-softened gutta-percha that, compacted, will make immediate contact with the dentin walls, while at the other end the cone, by virtue of its “tug-back,” occludes the apical foramen. Thus, the force is dissipated in a closed environment and the hydraulic pressure that develops within causes the sealer and the heat-softened gutta-percha to fill all the available spaces in a true corono-apical “wave of condensation”. The more coronal lateral canals are filled first, then gradually as the condensation wave moves api-
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! 27.33 The second plugger has completed its vertical compaction to the maximal working depth.
! 27.34 Reintroduction of the heat-carrier is softening the gutta-percha in the apical one third.
! 27.35 Another piece of gutta-percha has been removed. Now it is time to use the smallest plugger.
! 27.36 The smallest plugger has advanced, compacting the gutta-percha mass about 5 mm from the canal terminus.
The Schilder’s technique of vertical compaction of warm gutta-percha
2
3
The working level of compaction of the gutta-percha moves increasingly apically for two reasons. First, the gutta-percha mass softens and vertically compacts to automatically assume a lateral component of forces. This follows routine laws of physics and requires no lateral direction of the instrument on the part of the operator (! 26.42).5 Second, each introduction of the heat-carrier in the root canal is followed by the removal of a certain amount of gutta-percha that remained attached to the tip of the heating instrument as it begins to cool. Consequently, the wave of condensation and the working level of the pluggers are displaced increasingly apically and it becomes necessary to advance to the plugger of narrower size. The temperature of the apical gutta-percha gradually increases by a few degrees above body temperature. Since gutta-percha is a poor conductor of heat, its temperature will not rise immediately after the first or second application of heat. It will require several applications and even then, the temperature will not rise to hazardous levels. Studies performed with the help of thermocouples introduced into the root canal12 have demonstrated that the apical gutta-percha becomes moldable at a temperature 3°-7° C above body temperature and that it is impossible to elevate the temperature of this gutta-percha more than 9° C above the initial temperature, even if one attempted to do so deliberately.13
If we analyze the thermal profile of gutta-percha in the apical one third of the root canal (! 27.37), once the heat-carrier and then the narrower plugger have descended to a depth of about 5 mm from the apical foramen, we note that the thermal increase occurs gradually in concomitance with the various applications of heat, that the gutta-percha has become moldable at a tem-
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50 49 Temperature of apical gutta-percha (C)
cally, those of the middle third of the canal and finally those of the apical third and the ramifications of the delta. This hydraulic pressure is absent in lateral condensation, since in that technique the condensation never occurs in a “closed” space and the force applied to the gutta-percha is transmitted to the sealer, which finds an easy outlet coronally. This is one of several reasons why, with the lateral condensation technique, it is much more difficult to achieve filling of the lateral canals, even with sealer alone.
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Body temperature 1
2
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5
6
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12
Frequency of heat applications
! 27.37 Thermal profile of gutta-percha in the apical portion of the canal preparation.
perature 3°-7° C above body temperature, and finally that, if heat is not intentionally added, it returns to body temperature and will resist further movement beyond the terminus of the canal preparation.13,14 Apical control of the obturation is thus excellent, since the gutta-percha at the apex is never molten. It is contraindicated to descend further apically with the heat-carrier to heat the gutta-percha 2–3 mm from the apical foramen.15 Overheating and excessively plasticizing the apical gutta-percha increase the possibility of gutta-percha extruding beyond the terminus of the preparation.16 Stopping 5-6 mm short is more than sufficient to obtain an effective sealing or “corkage” of the canal preparation and filling of small lateral canals (! 27.38) or the apical delta (! 27.39) with gutta-percha and/or sealer. Furthermore, recently a new kind of gutta-percha cones has been introduced in the market, called “Conform Fit” (! 27.37), specifically designed for the obturation of root canals shaped with systems like ProTaper Gold®, WaveOne Gold®, ProTaper Next®, TruNatomy™ and similar ones. This new gutta-percha has the characteristic of having the heat transfer improved, since the heat is transmitted several millimeters ahead of the tip of the heat carrier (! 27.39). This is a big advantage during the compaction of warm gutta-percha in narrow and curved canals, where the metal instrument cannot reach the distance of 4-5 mm from the working length.
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! 27.38 a) An endodontically-treated maxillary central incisor extracted for periodontal reasons and cleared. Four lateral canals filled mostly with gutta-percha are evident. In this case, the compaction halted 5 mm from the canal terminus. b) Maxillary cuspid treated endodontically in vitro and then cleared. A lateral canal present about 4 mm from the apical foramen, is completely filled with gutta-percha. Heating and compacting were carried up to 5 mm from the terminus. c) Detail of the previous figure photographed at 64x magnification.
a
b
c
! 27.39 a) A cleared root demonstrates a small apical bifurcation filled with gutta-percha and sealer. The compaction occurred 5 mm from the canal terminus. b, c) Other examples of apical delta filled mainly with gutta-percha, heated, and compacted about 5 mm from the end of the canal preparation.
The Schilder’s technique of vertical compaction of warm gutta-percha
Reverse filling (“back-packing”) Once the gutta-percha has been compacted to about 5-6 mm from the terminus of the preparation, a radiograph is taken to verify that the gutta-percha has moved apically and that the obturation is well compacted (! 27.40, 27.41). At this point, it is necessary to fill in a backwards fashion the middle and coronal thirds of the canal, which were emptied during the previous phase of the obturation. The easiest and fastest way to perform the back-packing is using thermoplastic gutta-percha. If remnants of gutta-percha or sealer are left attached to the dentin walls from the previous phase of compaction, the gutta-percha used for the back-packing phase may adhere to this material before fusing with the apical mass of gutta-percha, thus leaving empty spaces affecting the uniformity of the obturation (! 27.42).17 If post space or canal retention are needed for prosthetic purposes, the clinician may choose to terminate the obturation at the deepest point of the apical com-
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paction or at any point of the reverse filling. Otherwise, the obturation can be completed up to the canal orifice and later partially removed to allow the necessary prosthetic space. In the single rooted tooth, the “back-packing” can be completed at any level since lateral canals that may have been present in the coronal or middle third of the canal have already been addressed during the downpacking (! 27.43). Furthermore, in anterior teeth, it is important to limit the backfilling to at least 2 mm below the gingival margin to prevent discoloration. Gutta-percha colorants reflecting through the coronal root and crown can cause unaesthetic pigmentation (see Chapter 35). In multirooted teeth, however, complete “back-packing” and obturation of the canals and pulp chamber are imperative due to the presence of accessory canals on the floor of the pulp chamber. In these cases, once the canals have been filled, it is also necessary to seal the pulp chamber. If left unsealed it may cause an inflammatory reaction in the tissues associated with the furcation area.8,18
c
d
! 27.40 a) Preoperative radiograph of maxillary left lateral incisor. b) Intraoperative radiograph of the cone fit. c) Radiograph of the apical compaction. The gutta-percha appears to be compacted for about 4 mm and then seems to fold. This is because the material has not been modified in the most apical portion. It is necessary to advance more apically with the heat-carrier and better compact the gutta-percha. d) Postoperative radiograph showing the obturation material being homogeneous and well compacted. The presence of a lateral canal has also been demonstrated by the filling material.
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! 27.41 a) Preoperative radiograph of a mandibular right second molar. b) Cone fit. c) Intraoperative radiograph of the apical compaction. The material appears to be homogeneous, but the obturation is slightly short. It is necessary to descend further apically (5 mm from the working length) with the heat-carrier and compact the gutta-percha better. d) Postoperative radiograph showing filling material also in the small apical bifurcation.
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! 27.42 a) During the initial phase of compaction, the plugger can leave streaks of gutta-percha along the walls (gray in the illustration). They must be re-directed toward the center of the root canal. b) Streaks left behind can create voids during the “back-packing” phase.
a
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! 27.43 a, b) The lateral canals that may be present are always filled during the downpacking.
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“Back-packing” with thermoplastic gutta-percha When using thermoplastic gutta-percha such as Obtura III (Spartan Corporation, USA), Beta 2 (B&L Bio Tech, Korea) (! 27.44), Elements™ (SybronEndo, USA), Calamus® (Dentsply Sirona, USA) (see ! 27.3c, d), the reverse filling of the canal can be performed effectively in a significantly shorter time, especially in multirooted teeth. This procedure is performed by introducing the narrowest needle (#23 or #25) into the root canal, and squeezing the trigger of the gutta-percha gun gently but decisively, so as to feel the pressure of the gutta-percha, which pushes the operator hand coronally as it accumulates in the canal. After the introduction of a small amount of gutta-percha, it is compacted by a corresponding size plugger. It is then re-heated by the heat-carrier and compacted again (! 27.45).
! 27.44 The Beta 2 (B&L Bio Tech, Seoul, Korea).
In general, with two/three successive introductions of material, “back-packing” of a canal is complete. It is always advisable to perform canal filling with thermoplastic gutta-percha in several injections (sectional technique), since better results are obtained (no entrapment of air bubbles) as compared to fillings performed in a single injection (single technique).19 The single injection technique is more prone to leave voids. According to Dr. Carl Nehammer (Lister House Endodontic Practice, London, UK), the trick to accomplishing a backfill without leaving voids is to slow down the process. Voids occur because the needle tip and the gutta-percha inside it are cooled when it comes into contact with the canal wall. The canal wall is 37° C and the needle tip is about 160° C (200° C at the heating chamber with a drop-off of heat toward the needle tip). When it touches the canal wall, the temperature of the sterling silver needle tip and the gutta-percha inside it immediately drops, often to non-plastic heat levels, thereby encouraging void formation. If the clinician simply places the needle in the canal and wait for a few seconds before pulling the trigger, the needle will re-heat itself and the gutta-percha inside it, as well as transmitting some of that heat to the canal wall and, more important, to the apically compacted gutta-percha, so that it can fuse together with the one injected by the syringe. All of these thermodynamic events reduce the chances of leaving voids.20 Another suggestion not to have voids is not to withdraw the hand during the injection with the syringe. Doing so may leave empty spaces. It is advisable to let it be guided by the pressure of the material accumulating within the root canal. Finally, in multirooted teeth, “back-packing” with thermoplastic gutta-percha can also be extended directly to the pulp chamber floor, since the gutta-percha issues from the instrument sufficiently thermosoftened as to be able to fill any accessory canals that may be present.
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! 27.45 a) The needle of the device touches and heats the apically compacted gutta-percha. Then a small amount of material is injected, in order to fill no more than 5 mm of space at a time. b) The plugger, previously used in the middle third, is now used to firmly compact the material until the gutta-percha is plastic. c) Additional 5 mm of gutta-percha are injected into the root canal. d) The compaction is completed using the larger plugger.
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Chapter 27
Obturation of communicating and confluent root canals In the case of two canals merging into a single foramen, the endodontist very often recognizes the convergence only when the radiograph of the cone fit is obtained. Individually, the cones advance unhindered to the desired maximal depth, but when they are placed simultaneously in the two canals, they advance only alternately: in the mesial root of a lower molar, for example, if the buccal descends, the lingual remains short and vice versa. This is clear proof that the two canals merge together, and only one of the two cones can be engaged at the apical foramen. The endodontist must thus decide which of the two it is preferable to advance to the apex; it should be the one which has better “tug-back” and that is found in the straighter and easier canal to obturate. The other is then shortened so that it touches the other cone. However, as already described in Chapter 17, it is important to diagnose the confluence of two canals at a common apex as early as possible to prevent useless over-instrumentation and transportation of the apical foramen, which could occur as a result of cleaning and shaping it twice from two different directions. When performing the obturation of two canals of the same root, the approach is different depending if the canals are confluent to a common apex (! 27.46) or they are independent (! 27.47).21
a
b
! 27.46 a) Mesial root of a mandibular molar. The transparent root shows two canals merging into a single foramen. b) The same anatomy is shown in this postoperative radiograph.
SINGLE FORAMEN In case of two canals merging to a single foramen (! 27.48a, b), at the time of compaction, each of the two cones must be inserted in its canal (simultaneous introduction) (! 27.48c, d), but the compaction must proceed with the cone that has been positioned at the foramen (alternate compaction). For the sake of convenience, this will be called the “first canal”. Only after the successful obturation of the apical third of this canal has been confirmed radiographically (! 27.48e, f) (the gutta-percha has moved apically and the obturation appears compacted), the operator can proceed with the compaction of the second cone of gutta-percha that will be pushed, heated, and compacted against the gutta-percha of the first canal (! 27.48g). If, instead of using this important trick, we perform the simultaneous downpacking in the two canals, short apical obturation may occur: the cone of the second canal could block the first cone before been pushed apically to reach the foramen and the final result could be a short apical obturation (! 27.49). This technique of downpacking must always be applied every time the clinician obturates two confluent canals of the same root, and more specifically in the mesial root of lower molars and in the mesiobuccal root of upper molars.
a
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! 27.47 a) The mesial canals of this mandibular molar have independent foramina. b) The same anatomy is shown in this postoperative radiograph.
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! 27.48 a) Preoperative radiograph of a lower right second molar. The tooth shows a single root with only two root canals, one distal and one mesial, which converge at a common apex. b) The drawing represents the root of figure a. c) Radiograph of the cone fit: the distal cone descends to the end of the preparation, while the mesial stops against the preceding one. d) Schematic drawing. e) Radiograph of the apical compaction of the distal canal: note that the mesial cone has been introduced into the canal but has not yet been compacted. It will be compacted after this radiograph has been checked for the distal canal. f) Schematic drawing. g) The compaction has been completed also in the mesial canal. h) Postoperative radiograph: note the extent of the confluence and its complete filling after compaction of the cone of the mesial canal. i) Two-year recall.
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! 27.49 The simultaneous compaction of two cones could impede the correct compaction of the cone fitted to the terminus of the canal. Packing the two gutta-percha cones at the same time could result in an inadequate apical seal, losing any further possibility to move more apically the gutta-percha of the distal canal.
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! 27.50 a) Cross section of the mesiobuccal root of an upper molar showing the presence of an isthmus between MB1 and MB2 b) Cross section of the mesial root of a lower molar showing the presence of an isthmus between the two mesial canals.
INDEPENDENT FORAMINA In case of two independent root canals of the same root, the operator should always suspect the presence of an isthmus (! 27.50a, b) and, therefore, a communication between the two canals (! 27.51). In such cases, at the time of obturation the two gutta-percha cones must be introduced simultaneously (as in the preceding case), and should also be compacted simultaneously (simultaneous compaction) (! 27.52). This serves to prevent the flow of obturating material through the isthmus in the second canal during the compaction of the first one, while the gutta-percha point has not been introduced yet in the second canal. That material will impede the introduction to the correct working length of the gutta-percha point of the second canal. Using the simultaneous compaction, the communication will be filled in more or less equal parts by the gutta-percha of the two cones. This technique of obturation must be applied any time one suspects communications, even among roots that appear to be independent. This prevents the obturating material introduced into the first canal during the compaction procedure from passing retrograde into the second canal through the natural communication, hindering proper filling of the latter (! 27.53).
! 27.51 The two canals of this lower canine have independent foramina but communicate at two different levels.
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! 27.52 a) Preoperative radiograph of a lower left second molar: the tooth has fused roots. b) Radiograph of a # 20 file at the radiographic terminus of the distal canal. c) Radiograph of the # 20 file at the radiographic terminus of the only mesial canal. d) Radiograph of the cone fit: the canals have independent foramina, but because they are in two fused roots, simultaneous compaction was performed, as the presence of communications was suspected. e) Radiograph of the apical compaction: note that filling of the communication at 2-3 mm from their respective foramina has been performed. f) Postoperative radiograph.
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! 27.53 a) Preoperative radiograph of a lower left second molar. b) Radiograph to verify the working length of the # 20 file at the radiographic terminus of the mesiobuccal canal. c) Intraoperative radiograph of the apical compaction of the distal canal: the material has refluxed in a retrograde manner into the mesiobuccal canal through the confluence, which was undetected. The material was then removed and the obturation completed by compacting the gutta-percha simultaneously in the three canals. d) Postoperative radiograph.
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Walter Hess work and postoperative radiographs In 1925, Walter Hess and Ernst Zürcher22 published a famous textbook on Root Canal Anatomy, after injecting vulcanized rubber in the root canals of 2.790 teeth and making these teeth transparent. The images showed how complex and bizarre is the root canal anatomy, so that today we speak in terms of “root canal system”. Of course, these images were very discouraging, since it was obvious the enormous difficulty to take care of all the complexities. And looking those images, two endodontists arrived through the years to opposite conclusions. Angelo Sargenti23 developed a “magic” sealer containing paraformaldehyde which was supposed to “mummify” all the contents of the “crazy” anatomy: pulp tissue and bacteria, so that the clinicians did not have to worry about cleaning, shaping and obturating lateral canals, isthmuses, bifurcations etc.
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Herbert Schilder,9 on the other hand, has taught that with instruments we can work and shape the canal that can be negotiated, while with irrigating solutions like sodium hypochlorite, we can digest and remove all the organic materials present in the remaining complex root canal anatomy. Once the space is completely empty, we can fill the same space with a thermo-plasticized material vertically compacted. The softened gutta-percha mass, which is being compacted vertically into the conically shaped canal preparation, automatically assumes a lateral component of force. This follows routine laws of physics (Law of Pascal of hydrodynamics) and requires no lateral direction of the instrument on the part of the operator.5 If this is true, in our post-operative radiographs, we should be able to see the same “bizarre” anatomy like the ones showed many years ago by Walter Hess.22 And this is exactly what happens, if we follow a precise protocol (! 27.54a-g).
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! 27.54 a-g) Original images from Hess’s work showing the internal morphology of different teeth followed by postoperative radiographs showing similar anatomy. All cases have been treated with the Vertical Compaction of Warm Gutta-percha, according to the Schilder’s technique.
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The importance of obturating lateral canals If we believe in the existence of the “root canal system” and if we believe in the communications between the endodontium and the periodontium and in their role as “portals of exit” of pathology, then we should agree that all the portals of exit have the same importance and the same responsibility in determining the beginning and the growth of lesions of endodontic origin (! 27.55). Bacteria do not make any difference if they are in the main canal or in a lateral canal. They need to be eliminated and the “lateral opening” needs to be sealed exactly like the main apical foramen (! 27.56). Now the question is: how can we clean, shape and obturate the lateral canals? First of all, the introduction of an endodontic instrument in a lateral canal most of the time happens by chance (! 27.57) and it is not intentional (! 27.58, 27.59). Second, we do not need to “shape” lateral canals, especially considering that in necrotic cases we may suspect the presence of a lateral canal because of the presence of a “lateral” lesion (! 27.60), while in vital cases it will be impossible to know in advance the presence of the lateral ramification.
! 27.55 Each portal of exit from the root canal system, that is, each foramen, becomes the sites of entry for bacterial toxins and tissue breakdown products into the periodontal ligament and periradicular tissue (modified from: Nguyen TN. Obturation of the root canal system. In: Cohen S, Burns RC eds. Pathways of the pulp. 4th ed. St. Louis: Mosby; 1987.
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In conclusion, if on one side lateral canals are impossible to detect and most of the time impossible to be negotiated, on the other hand they do not require any particular effort or any particular instrument by the endodontist: the irrigating solution if properly used2428 will digest their content (see ! 16.8, 27.61) and the softened obturating material vertically compacted will automatically seal them (! 27.62).5 Of course, since these accessory canals are not shaped, they do not have any taper and therefore there is no way to control the “apical” extent of the obturating material. Therefore, quite often we have a small extrusion of sealer (! 27.63). However, the use of non-toxic sealer, like the Grossman sealer and all the sealers based on zinc oxide-eugenol, will not cause any problem, and even though they are not biocompatible, they are very well tolerated by the organisms and for sure they are not responsible of any failure. Besides, new biocompatible bioceramic sealers are becoming more and more popular so that the little extrusion will not represent a problem anymore for anybody. The lack of seal of a lateral canal can often be responsible of a failure and require a non-surgical (! 27.6427.68) or a surgical retreatment (! 27.69, 27.70).29
! 27.56 Postoperative radiograph of a maxillary left second premolar and second molar. The exit of the lateral canal of the molar appears to be larger than the apical foramen.
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! 27.57 a) Preoperative radiograph of a maxillary right first molar. b) Intraoperative radiograph. The file is negotiating a lateral foramen on the mesial aspect of the palatal root. c) The file has been removed, pre-curved and introduced in the same canal oriented toward the distal aspect and now is negotiating the main foramen. d) Postoperative radiograph. The presence of the lateral canal obturated with warm gutta-percha and sealer is evident. e) 2-year recall.
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! 27.58 a) Intraoperative radiograph. One file is negotiating the main canal, and another one has been introduced in the lateral foramen. b) 2-year recall.
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! 27.59 a) Intraoperative radiograph. Two files are negotiating the apical ramification. b) 2-year recall.
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! 27.60 a) Preoperative radiograph of a mandibular right first molar. A gutta-percha cone has been introduced in the fistulous tract originating from the lateral lesion. Obviously that lesion is maintained by bacteria of the lateral canal. b) 2-year recall. It is evident the obturation of the lateral canal and the complete healing of both apical and lateral lesions.
! 27.61 SEM images showing few examples of apical ramifications and lateral canals free of pulp tissue and debris.
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! 27.62 a, b) The clarified tooth shows a lateral canal about 4 mm from the apical foramen entirely filled with warm gutta-percha. c) SEM photograph showing a lateral canal filled with warm gutta-percha.
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! 27.63 a) Preoperative radiograph of a maxillary right second premolar. There is an apical lesion and a lateral lesion. b) 2-year recall showing the obturation of the lateral canal and the complete healing of both apical and lateral lesions.
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! 27.64 a) Preoperative radiograph of a maxillary right second premolar. The large lesion is on the distal aspect of the root, which means it is maintained by a lateral canal present on the distal aspect of the root canal. b) 2-year recall showing the obturation of the lateral canal and the complete healing of the large lesion.
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! 27.65 a) A sinus tract is originating from the lesion present in the bifurcation. b) During the non-surgical retreatment the lateral canal responsible of the lesion has been filled. c) The 6-month recall radiograph shows a nice healing. (Courtesy of Prof. Elio Berutti, Turin, Italy.)
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! 27.66 A. Preoperative radiograph of the upper right central incisor. A radiolucency is present on the mesial aspect of the middle one third of the root. B. Postoperative radiograph. Three or may be four lateral canals have been obturated during the non-surgical retreatment. C. 1-year recall. (Courtesy of Dr. Clifford Ruddle, Santa Barbara, CA, USA.)
! 27.67 a) A radiolucency is present between the mesio-buccal root of the second molar and the disto-buccal root of the first molar. b) During the non-surgical retreatment, a lateral canal has been filled on the mesial aspect of the mesio-buccal root of the second molar. c) 2-year recall.
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! 27.68 a) Non-surgical retreatment of a surgical failure. A radiolucency is present on the mesial aspect of the apical one third, just below the amalgam retrofill. The lateral canal responsible has been filled. b) 2-year recall.
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! 27.69 Surgical therapy of a lateral lesion. a) Preoperative radiograph of a maxillary left second premolar. A lateral lesion is present. b) Through a surgical flap, the lateral canal responsible for the lesion was obturated with Super EBA. c) Postoperative radiograph. d) 2-year recall showing the obturation of the lateral canal and the complete healing of the lateral lesion.
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! 27.70 Surgical therapy of a lateral lesion. a) Preoperative radiograph of a maxillary right second premolar. A radiolucency is present on the distal aspect of the root and a sinus tract is also present. b) Through a surgical flap, the lateral canal responsible for the lesion was obturated with Super EBA. c) 2-year recall showing the complete healing of the lateral lesion.
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REFERENCES 1. Nguyen TN. Obturation of the root canal system. In: Cohen S, Burns RC eds. Pathways of the pulp. 4th ed. St. Louis: Mosby; 1987. 2. Frank AL, Simon JHS, Abou-Rass M, et al. Clinical and surgical endodontics: concepts in practice. Philadelphia: Lippincott; 1983. 3. Weine FS. Endodontic therapy. 3rd ed. St. Louis: Mosby; 1982. 4. Schilder H. Filling root canals in three dimensions. J Endodontics 2006;32(4):281-90. 5. Schilder H. Vertical compaction of warm gutta-percha. in Gerstein H: Techniques in clinical endodontics. Philadelphia: Saunders; 1983. pp. 76-98. 6. Vogel G, Carrassi A, Abati S. Comparazione di tre differenti tecniche di otturazione endocanalare. Studio con il microscopio elettronico a scansione. Mondo Odontostomatologico. 1984;6:13. 7. Weiner BH, Schilder H. A comparative study of important physical properties of various root canal sealers. II. Evaluation of dimensional changes. Oral Surg Oral Med Oral Pathol. 1971;32(6):928-37. 8. Lavagnoli G. Otturazione del canale radicolare. In: Pecchioni A. Endodonzia. Manuale di tecnica operativa, IV ed. Milano: I.C.A; 1986. 9. Schilder H. Canal debridement and disinfection. In: Cohen S, Burns RC eds. Pathways of the pulp. 2nd ed. St. Louis: Mosby; 1980. 10. Ruddle JC. Three-dimensional obturation of the root canal system. Dentistry Today. 1992. 11. Casanova F. Understanding of some
clinically significant physical properties of Kerr sealer through investigation. Thesis. Boston University, 1975. 12. Goodman A. Schilder H, Aldrich W. The thermo-mechanical properties of gutta-percha. Part IV. A thermal profile of the warm gutta-percha packing procedure. Oral Surg Oral Med Oral Pathol. 1981;51(5):544-51. 13. Goodman A. Thermo-mechanical properties of gutta-percha. Thesis. Boston University; 1973. 14. Blum JY, Parahy E, Machtou P. Warm vertical compaction sequences in relation to gutta-percha temperature. J Endod. 1997:23:307-11. 15. Berutti E, Fariba AA. La condensazione verticale della guttaperca. Il Dentista Moderno 1985;8:1539. 16. Schilder H. Advanced course in Endodontics. Boston University School of Graduate Dentistry. Boston, MA, 1978. 17. Schilder H. Guttaperca calda. Attualità Dentale III. 1987;19:12. 18. Berutti E, Marini R. L’importanza di una corretta otturazione tridimensionale della camera pulpare nella terapia endodontica. Pratica Odontoiatrica 1987;4:16-25. 19. Veis A, Beltes P, Liolios E. Sealing ability of thermoplasticized gutta-percha in root canal obturation using a sectional vs. a single-phase technique. Endod. Dent. Traumatol. 1989;5:87-91. 20. Buchanan LS. Continuous wave of condensation technique. Endod Practice 1998;1(4):7-10. 21. Castellucci A. Two canals in a single root: clinical and practical considerations. Endod Practice. 2001;17-23.
22. Hess W, Zürcher E. The anatomy of the root-canals of the teeth of the permanent dentition - the anatomy of the root-canals of the teeth of the deciduous dentition and of the first permanent molars. London: J. Bale Sons & Danielsson; 1925. 23. Sargenti A. Debate on N2: Is N2 an acceptable method of treatment? Trans Int Conf Endod. 1973;5:176-95. 24. de Gregorio C, Estevez R, Cisneros R, et al. Efficacy of different irrigation and activation systems on the penetration of sodium hypochlorite into simulated lateral canals and up to working length: an in vitro study. J Endod. 2010;36(7):1216-21. 25. Van der Sluis L, Wu M, Wesselink P. The efficacy of ultrasonic irrigation to remove artificially placed dentine debris from human root canals prepared using instruments of varying taper. Int Endod J. 2005;38:764-68. 26. Lee S-J, Wu M-K, Wesselink PR. The effectiveness of syringe irrigation and ultrasonics to remove debris from simulated irregularities within prepared root canal walls. Int Endod J. 2004;37:672-78. 27. Al-Jadaa A, PaquÉ F, Attin T, et al. Necrotic pulp tissue dissolution by passive ultrasonic irrigation in simulated accessory canals: impact of canal location and angulation. Int Endod J. 2009;42:59-65. 28. Al-Jadaa A, PaquÉ F, Attin T, et al. Acoustic hypochlorite activation in simulated curved canals. J Endod. 2009;35:1408-11. 29. Castellucci A. The importance of obturating lateral canals. Conference at the AAE Meeting. San Francisco, April 2016.
