Crash Course in Endodontics

CRASH COURSE IN
ENDODONTICS
WWW.DENTISCOPE.ORG
DONE BY : SIMA HABRAWI

EDIT BY : HAIF ALQAHTANI DENTISCOPE 2020
Crash Course in Endodontics
Table of Contents
Pulp anatomy ........................................................................................................................ 4
Endodontic microbiology ....................................................................................................... 6
Diagnosis and treatment planning ......................................................................................... 7
Pulp sensibility tests .......................................................................................................................7
Pulp diagnosis ................................................................................................................................9
Peri apical diagnosis ..................................................................................................................... 10
Decision tree for Pulpal Diagnosis .................................................................................................13
Decision tree for Periapical Diagnosis............................................................................................ 13
Pulp therapies ..................................................................................................................... 13
Cavity sealers ............................................................................................................................... 14
Cavity bases .................................................................................................................................14
Cavity Liners.................................................................................................................................14
Pulp capping ................................................................................................................................ 14
Pulpotomy ................................................................................................................................... 15
Pulpectomy .................................................................................................................................. 15
Endodontic radiography ...................................................................................................... 16
Radiographic techniques: ............................................................................................................. 16
Endodontic instruments ....................................................................................................... 18
Hand instruments......................................................................................................................... 18
Nickel titanium instruments: NiTi.................................................................................................. 19
Endodontic procedure .......................................................................................................... 21
Acess cavity.................................................................................................................................. 21
Special cases ................................................................................................................................ 22
Working length estimation ........................................................................................................... 23
Biomechanical preparation ........................................................................................................... 24
Instrumentation Motions ............................................................................................................. 24
Instrumentation techniques ......................................................................................................... 24
Irrigation ...................................................................................................................................... 26
Intracanal medication................................................................................................................... 28
Temporization .............................................................................................................................. 30
Done By : Sima Habrawi Dentiscope 2020

Edit By : Haif AlQahtani Page 1 of 104
Obturation ................................................................................................................................... 32
Sealers ......................................................................................................................................... 33
Obturation techniques: ................................................................................................................ 34
Clinical endodontics ............................................................................................................. 35
Anesthesia ................................................................................................................................... 36
Accidents in root canal preparation .............................................................................................. 40
Accidents in obturation ................................................................................................................ 41
Endodontic procedures- case selection ................................................................................. 43
Endodontic emergencies ...................................................................................................... 44
Antibiotic guidelines..................................................................................................................... 45
Single visit endodontics........................................................................................................ 46
Latest advancements in endodontics .................................................................................... 47
Advancements in diagnosis:.......................................................................................................... 47
Advancements in root canal prep :................................................................................................ 47
Access cavity: ....................................................................................................................................................... 47
Root canal irrigation: ........................................................................................................................................... 48
Cleaning and shaping: ......................................................................................................................................... 49
Rotary endodontics .............................................................................................................. 51

Gates Glidden burs: [GG] .............................................................................................................. 51
NiTi rotary instruments: ............................................................................................................... 51
Latest advancements in obturation ...................................................................................... 55
Obturation techniques ................................................................................................................. 55
Apical barrier ............................................................................................................................... 57
Restoration of endo treated teeth ........................................................................................ 58
Post and core: .............................................................................................................................. 59
Endocrown ................................................................................................................................... 59
Nayyar Core .................................................................................................................................60
Bleaching of vital and non vital teeth ................................................................................... 65
Home bleaching ........................................................................................................................... 66
In office bleaching ........................................................................................................................ 66
Lasers in endodontics ........................................................................................................... 68
Regenerative endodontics ................................................................................................... 69

Apexogenesis ............................................................................................................................... 69
Apexification ................................................................................................................................ 69
Root canal revascularization ......................................................................................................... 69
Dental trauma ..................................................................................................................... 71
Trauma classification .................................................................................................................... 71
Tissue response to trauma ............................................................................................................ 74
Dental trauma management................................................................................................ 78
General guidelines for trauma management: ................................................................................ 78
Management of complicated / uncomplicated crown fractures ..................................................... 79
Management of crown / root fractures ......................................................................................... 82
Management of root fractures ...................................................................................................... 82
Management of concussion / subluxation ..................................................................................... 83
Management of extrusion / lateral luxation .................................................................................. 83
Management of intrusion ............................................................................................................. 84
Management of avulsion .............................................................................................................. 85
Medications in trauma cases :....................................................................................................... 89
Management of root resorption ........................................................................................... 90
invasive cervical resorption - ICR .......................................................................................... 91
Summary of trauma management ....................................................................................... 94
Endodontic surgery .............................................................................................................. 96
Flap designs .................................................................................................................................98
Retrograde filling materials ........................................................................................................ 101
References......................................................................................................................... 103
Disclaimer ....................................................................................................................... 104

Pulp anatomy
1- Central region :
a. Cells [ odontoblasts + fibroblasts + undifferentiated mesenchymal
cells + defense cells ]
b. Matrix [ collagen type 1 and 2]
c. ground substance [ gylcosamino glycans and glycoproteins]
d. Bvs
e. Nerves [ subodontogenic plexus of rashkow + sensory afferent from
trigeminal nerve ]
2- Peripheral region:
a- Odontoblastic layer
b- Cell free layer – zone of weil
c- Cell rich layer
Blood and nerve supply
• A – FIBERS = largest diameter - fast conducting → localized sharp pain

• C- FIBERS = smallest diameter – slow conducting → dull / throbbing pain
** when you use the EPT the A fibers get stimulated at first then as the intensity increases c- fibers
get stimulated as well.
Pulp develops from the ectomesencymal cells of the dental papilla, when the odontoblasts form
dentine → the dental papilla changes into the pulp
Functions of the pulp:
1- Formation of the dentine
2- Maintain tooth fluid movement
3- Sensation
4- Proprioception
5- Defense [ by blood supply forming reparative and secondary dentine ]
Pulp has minimal collateral supply which reduces its capacity for repair

Innervation of pulp is both simple and complex
 Simple – only free nerve endings and so lacks proprioception

 Complex – innervation of odontoblastic process which produces high level of sensitivity to
thermal and chemical change
Causes of pulpal disease: [ pathways bacteria can enter into the pulp]
1- Caries - Most common cause of pulpal disease is bacterial contamination from caries ,
percolation around restorations
2- Trauma [ fractures, luxation, avulsion or chronic trauma like bruxism]
3- Marginal leakage around restorations or during cavity prep
4- Periodontal pockets : through lateral canal and exposed DT
5- Anachoresis: transportation of microbes through blood or lymph to a site of inflammation –
does not occur in humans
Q: can radiation cause pulpal disease? Radiation affects the pulpal blood supply → pulpal necrosis ,
radiation also affects the salivary glands leading to hyposalivation → caries and pulpal disease
Q: how can caries cause pulpal inflammation? Carious lesions contain bacteria that get lesser as you
get closer to the pulp but the pulp gets affected before the actual bacterial invasion by the noxious
bacterial by- products. Once the pulp gets exposed to the bacteria → PMN infiltrate the pulp causing
liquefactive necrosis that spreads throughout the pulp
**Pulpal infections are polymicrobial but anaerobes dominate
Complications of untreated Pulpitis:
• Upper teeth → sinusitis → meningitis / brain abscess / orbital cellulitis and cavernous sinus
thrombosis
• Lower teeth → ludwig’s angina / parapharyngeal abscess / mediastinitis / pericarditis
/emphysema

Endodontic microbiology
The main objective of endodontic treatment = prevention or elimination of apical periodontitis
• Colonization = establishment of microorganisms in a host

• Infection= when bacteria damage the host and produce signs and symptoms
• Pathogenicity = the ability of a microorganism to cause a disease / virulence = the degree of
pathogenicity under certain circumstances
Q:What are the defense mechanisms of DT to prevent bacterial entry if cementum is exposed?
1- Outward flow of dentinal fluid
2- Presence of Odontoblastic processes
3- Presence of mineralized crystals and macromolecules like immunoglobins
➢ A positive correlation exists between the number of bacteria in an infected root canal and the
size of periradicular radiolucencies. [ the more the bacteria the larger the RL]
➢ No absolute correlation has been made between any species of bacteria and the severity of
endodontic infections.
➢ when a PA granuloma forms → it prevents the spread of infection to the surrounding tissue [
a granuloma is the place where bacteria is killed]
Types of microorganisms present in bacterial infections:
1- Aerobes [ streptococci species]
2- An aerobes [ enterococci, bacteroides , actinomyces]
3- Fungi
4- Viruses – only in non – inflamed pulps of HIV / herpes pts
5- Spirochetes
6- Fusobacteria – associated with severe pain, swelling, flare ups
**e.faecalis is mostly present in re infection cases – most resistant bacterial species .

Diagnosis and treatment planning

▪If you are in doubt postpone initiating treatment until symptoms localize
▪Diagnosis must always include identification of the cause of the disease so it can be
removed
1- History:
Chief complaint [ when did it start, where is the pain, describe the pain [ throbbing, sharp, dull etc ] ,
provoking and alleviating factors]
2- Clinical examination:
Soft tissue : [ look for redness, swelling, sinus tracts etc ]
Hard tissue : [ examine tooth structure for caries, fracture , exposed dentine, integrity of current
restorations if present, check restorability of the tooth ]
Pulp sensibility tests - reproduce the pt’s symptoms [ you need at least 2 signs and
symptoms to confirm a disease]
You always test the suspicious tooth LAST – do the test on an adjacent tooth + contralateral tooth
and a tooth from the opposing arch.
1- Electrical pulp test [ EPT]
- Gives no indication about vascular blood supply
- Make sure the field is dry and apply conductive paste [ toothpaste or prophy paste] – apply EPT
on the buccal surface of the tooth
- If the tooth is crowned → apply EPT on the margin of the crown
- EPT reaches a high # and the pt doesn’t feel anything → -ve response
Causes of false positive of EPT Causes of false negative of EPT

1- stimulation of nerve fibers in the 1- Inadequate contact with the stimulus.
periodontium or adjacent tooth 2- Tooth calcification
2- In multirooted teeth one canal might be non 3- Immature apical development
vital and the rest might be vital 4- Traumatic injury
3- Not objective test because it depends on 5- The test is subjective (Not objective)
pt’s response 6- Regressive neural changes in elderly
4- C- fibers might still be present in the pulp [ patients
more resistant to necrosis] 7- Patients who have taken analgesics
5- Cell bodies of neurons are located in
ganglia outside the pulp
2- Heat testing [ only used if the CC is pain on hot food / drink ] – you can use:
A. Heated Gutta percha / hot compound stick
B. Dry rubber prophylaxis cup
C. Hot water under rubber dam isolation [ best for testing full coverage restorations]
- Apply a lubricant [petroleum gel] onto the tooth surface to prevent hot material from sticking -
then place the heated GP or hot compound stick on the buccal surface
3- Cold testing [ used when the CC is pain to cold ] – you can use :
A. Ice sticks [ rarely used because cold water will leak into the gingiva and cause a false
positive response ]
B. Ethyl chloride spray [ best ]

C. Carbon dioxide [ dry ice sticks – extremely cold and can cause infraction lines in the
enamel or pulpal damage]
** in case you need to repeat the cold test – wait for 5 mins
** in electrical / thermal pulp testing → A- delta fibers conduct the pain [ sharp and well localized] –
but in case of inflammation C – fibers are activated [ not very well localized pain]
** electrical and thermal pulp tests are called sensibility tests because they only indicate nerve
response not blood supply [ we assume since there is nerve response that the pulp has viable blood
supply and is vital]
4- Cavity test :
- Drilling the tooth without LA to ensure a negative response to cold/ hot test [ specially when
you can’t notice a direct reason for necrosis]
- Used if all the other tests an inconclusive
Other tests that should be done during endo diagnosis:

1- Percussion test: when the inflammation spreads from the pulp to the PDL → the ability to
localize the pain increases [ because the PDL contains proprioceptive fibers]
- Tapping on incisal or occlusal surface by [ digital pressure, end of a hand instrument , tooth
sloth or a cotton swab] → TTP indicates periapical involvement
- Always do percussion test first with your finger then with the handle of an instrument
** tooth slooth allows the application of forces on individual cusps → very
useful to detect fractured teeth
Ask the pt to bite down deeply and slowly then open very quickly- If the pain
occurs on releasing → cracked tooth
To check for cracked tooth :
• Anterior tooth → transillumination

• Posterior tooth → bite test
other causes of +ve percussion test :
1- Traumatic occlusion / trauma injury
2- High restoration
3- Cracked tooth or vertical root fracture
4- Maxillary sinusitis
5- Periodontal abscess
2- Palpation test: when inflammation spreads beyond cortical bone → swelling can be detected
by digital palpation
3- Mobility: done in buccolingual direction using index finger and the back of a hand instrument
Grade 1 Crown moves up to 1 mm in horizontal direction
Grade 2 Crown moves more than 1 mm in horizontal direction
Grade 3 Crown moves horizontally and vertically [ easily displaced in the socket]
4- Periodontal probing: around the entire circumference of the tooth to detect any pockets and
bone loss that might not be showing on xray
Causes of isolated deep pockets:

1- Periodontal disease
2- PA pathology draining through the periodontium
3- Developmental defect like Vertical grooves
4- Vertical root fracture
5- External root resorption
To detect cracks or fractures:
- Fiber optic transillumination can be used to detect cracks [ the piece closer to
the light will appear brighter]
- dye staining : dye is applied inside the access cavity and then re examined
after one week.
Radiolucent lesion associated with a vital tooth is NOT FROM ENDODONTIC
ORIGIN
PA radiolucency resulting from pulp necrosis has “ hanging drop appearance” –
beginning on the lateral surface of the root then extending apically. – this
lesion does not change location when angles radiographs are taken.
Sinus tract tracing is done using GP size 35
Pulp diagnosis
PULP SYMPTOMS /TESTS TREATMENT

DIAGNOSIS
SYMPTOMS: No treatment
Asymptomatic needed
PULP TESTS:
Moderate response to electric pulp test [EPT] – response subsides upon
NORMAL
removal of stimulus
Sharp response to cold test but disappears upon removal of stimulus
RADIOGRAPHS:
Intact lamina dura , no resorption, no calcification or pulp abnormality
SYMPTOMS: Remove caries ,
• Sharp pain that stops upon the removal of Adjust occlusion
stimulus - Stimulus might be [ hot, cold, sweet] Apply
• Pain can only be localized with cold stimulus appropriate
History: recent dental tx, cervical erosion / abrasion base under the
PULP TESTS: restoration
REVERSIBLE
PULPITIS EPT and Heat test = normal
Cold test = exaggerated response that diminishes
with the removal of stimulus
Percussion = no pain
RADIOGRAPHS:
Caries or a restoration without an underlying base.
Normal PA and PDL width

SYMPTOMS: Pulpotomy or
• Spontaneous intense pain – pain does not subside upon removal of pulpectomy
stimulus **
• Pain at night **
• Pain localization with hot stimulus
• Referred pain is seen
History: deep caries , trauma , large
IRREVERSIBLE restoration
PULPITTIS PULP TESTS:
EPT = elevated
Heat test = acute pain
Cold test = exaggerated response that
lingers for around 30 sec (even after removal
of the stimulus )
Percussion= if PDL is involved → TTP
RADIOGRAPHS:
Caries, defective restoration, might have PDL widening
Symptoms: RCT
Dry necrosis [ no tissue element in the pulp space]
Liquefactive necrosis [ pulp tissue but without vascular element] – more
likely to cause symptoms and less likely to cause PA pathosis
NECROTIC
Pulp tests:
PULP
EPT / cold test / heat test = no response **
Radiograph:
Large caries, large restoration , PDL widening an PA radiolucency might be
present [ in this case tooth might be TTP]
Peri apical diagnosis

PERI APICAL SYMPTOMS / TESTS MANAGEMENT
DIAGNOSIS
A. Symptomatic : [ acute] Symptomatic:
TTP and pain on chewing** Remove the cause
PDL within normal limits – can occur around vital and non-vital Vital tooth → might
teeth need occlusal
Causes: adjustment
1- Mechanical or chemical irritation from endo treatment Non vital tooth → RCT
2- Hyper occlusion [ vital pulp] Asymptomatic:
3- Inflammatory mediators from inflamed pulp RCT
4- Microbial toxins from necrotic pulp
APICAL
PERIODONTITIS
B. Asymptomatic: [ chronic]
Only with non vital teeth – no pain**
Radiograph : wide PDL or a radiolucency
Asymptomatic apical periodontitis has 2 histological variants :
1- Peri apical granuloma:

Chronically inflamed granulation tissue at the apex of the tooth
Symptoms:

1- Asymptomatic [ discovered on routine radiographs] ** extension of

2- No TTP/ No mobility inflammation from
3- No response to EPT / thermal test pulp to PA region
Radiograph : can lead to
1- Widening of the PDL near the apex granuloma
2- Well circumscribed or poorly defined lesion formation →
Some root resorption proliferation of
Management : epithelium → cavity
Restorable tooth → RCT [ to eliminate microorganisms in PA filled with fluid and
region] lined by stratified
Non restorable tooth → extraction + curettage squamous
2- Radicular cyst : epithelium → a cyst
Extension of the inflammation from the pulp to the PDL [ the only way to
Symptoms: know if the PA
1- Asymptomatic [ discovered on routine radiolucency is
radiographs] granuloma or cyst
2- Involved tooth might be non vital or has a is by histological
failed RCT section]
Radiograph : ** the epithelium
Well defined radiolucency surrounded by a narrow in radicular cysts
radio opaque margin comes from
Management: epithelial cell rest
1- RCT of malassez
2- Extraction You always do RCT
3- Marsupialization [ for large cysts] first if it heals → it
4- Apicectomy was a granuloma it
5- Enucleation not then it is a cyst
→ surgical removal
is indicated
Localized collection of pus in the alveolar bone at the apex of the 1. Drainage by:
tooth – caused by bacterial invasion into the periapical tissue A. RCT
following pulp necrosis B. Incision and
Symptoms: drainage
1- Rapid onset spontaneous pain C. If non restorable
2- pain to percussion and palpation** tooth or for financial
3- fluctuant swelling ** reasons / pt pref →
4- systemic manifestations ** extraction
Diagnosis : 2.Relieve the tooth out
1- Clinical examination [ TTP] of occlusion
ACUTE APICAL 2- Pulp tests → Pulp is necrotic 3. NSAIDs to control
ABSCESS ** phoenix abscess =acute exacerbation pain
of a chronic lesion ** if there are systemic
Radiograph: complications → fever ,
Might show slightly thickened PDL lymphadenopathy,
chronic apical abscess: cellulitis → give ABX
• Asymptomatic
• necrotic pulp
• formation of a sinus tract [ tracing of sinus tracts is done using
size 35 GP]
sinus tract can drain to [ facial skin, gingival sulcus , oral mucosa] Tx of chronic abscess =
RCT

A type of chronic apical periodontitis to a

long standing irritant [ tooth can be vital
or non- vital]
CONDENSING
Asymptomatic
OSTEITITS
Radiograph shows increased PA radio
opacity
• Most diagnostic symptom of symptomatic apical periodontitis = pain on chewing / TTP

• Most diagnostic symptom of radicular cyst = well defined radiolucency at the apex
• Most diagnostic symptom of acute apical abscess = swelling
• Most diagnostic symptom of chronic abscess = sinus tract
Acute apical abscess is distinguished from lateral periodontal abscess by pulp vitality test. [ apical
Acute apical abscess Periodontal abscess
Pulsating, pounding continuous pain Dull pain
Easy to localize Localized by probing
Continuous pain at night No pain at night
Tooth is mobile Tooth is not mobile
EPT/ COLD/ HEAT TEST = no response EPT/ COLD/ HEAT TEST = normal
Swelling is present Occasional swelling
Radiograph = caries or defective restoration Radiograph = foreign body / vertical bone loss
TX= drainage + ABX [ if needed ] + analgesics TX = remove foreign body + SRP
abscess → pulp is non vital]
Management of abscess:
1- Identify and remove the cause
2- RCT or if large do incision and drainage [ I&D ]
3- In case of fever, malaise, trismus, progressive swelling → ABX
▪ Amoxycillin 500mg (child 10mg/kg up to 500mg) orally every 8 hours for 5 days
▪ If hypersensitive to penicillin then → Clindamycin 300mg (child 7.5mg/kg up to 300mg) every 8
hours for 5 days
▪ Unresponsive infections : Amoxycillin+ clavulanate 875 +125mg (child 22.5 + 3.2mg/kg up to
875+125mg) orally every 12 hours 5 days
In case of deep infections like ludwig’s angina → air way is compromised the pt must be referred to
a hospital to maintain airway and provide drainage

Decision tree for Pulpal

Diagnosis
Decision tree for

Periapical Diagnosis
References:
-A clinical classification of the status of the pulp and the root canal system. PV Abbott,C Yu.
-Cohen's Pathways
Edit By : Haif AlQahtani of the Pulp - 11th Page 13 of 104
Pulp therapies
Q: what decides what type of pulpal protection is needed ? the remaining dentine thickness [ RDT ]
Cavity sealers: [ cavity varnish / bonding agents ]

• seal the DT to protect the pulp from chemical / bacterial irritation
• Usually used under amalgam
• Not used under composite / GIC [ interferes with adhesion & polymerization]
Cavity Liners : few microns → Cavity bases : few mm thick →

physical barrier against bacteria + some thermal and mechanical protection +
therapeutic effect like Fluoride release replace missing dentine or block out
and antibacterial properties [ CaOH2 undercuts. [ Zinc phosphate , zinc
&GIC] polycarboxylate , GIC ]
Pulp capping: procedures done when

there is a near exposure or an actual pulp
exposure - to maintain pulp vitality and limit
the need for further endodontic treatments.
pulp capping is contraindicated if the tooth
will have extensive restoration ,
pathological exposure
Mechanical exposure (accidental) occurs
during the cleaning of the affected dentine.
In cases of carious (pathological) exposure,
the bacteria has already reached the pulp.
Requirements of pulp capping :

1- Asymptomatic tooth
2- Hemorrhage can be easily controlled
3- Pulp is not inflamed or has signs of reversible pulpitis
4- No PA pathology [ no radiolucency or TTP]

Indirect pulp capping Direct pulp capping

Done to avoid accidental pulp exposure in deep In case of accidental pulp exposure
cavities
- Pinpoint exposure less than 0.5 cm
You can use : - Hemorrhage must be easily controlled
– Ledermix Cement - Minimal contamination [ done under rubber dam]
– Calcium hydroxide [ Lfie, Dycal ] You can use :
– Zinc oxide-eugenol (ZOE) – reduce – Ledermix Cement
inflammation + pain – Calcium hydroxide [ Lfie, Dycal ]
– Glass-ionomer cement (GIC) Both are susceptible to dissolution and must be
covered by base [ GIC ]
** Ca(OH)2 is the gold standard for pulp capping but it has poor bonding to dentine , high material
resorption and mechanical instability
** biodentine = similar action compared to calcium hydroxide but without the drawbacks
Biodentine can be used for: direct / indirect pulp capping – pulpotomy – tx of external and internal
root resorption – apexification
Pulpotomy :
- Differs from direct pulp capping in that a portion of remaining coronal pulp is removed before
application of medicament. [ radicular pulp is not removed]
- Usually better than pulp capping for primary teeth.
- Most often used following trauma.
Pulpectomy : RCT [ coronal and radicular pulp is removed]

Endodontic radiography
Radiographs are needed in endo for:
1- Diagnosis [ pre operative radiograph]
- Identify any PA pathology
- Identify pulpal anatomy + number and curvature of the roots and canals
2- Working radiographs
- Working length estimation , master cone confirmation , obturation confirmation
3- Post op radiograph of the RCT or after trauma [ monitor for healing or development of any
PA pathology]
Radiographic techniques:
1- Angle bisecting technique:
2- Parallel technique :
More accurate**
Causes 10% magnification [ magnification can be minimized by rectangular collimation and
long cones ]
Ex: if a tooth is 21 mm long it will appear 23 mm on a parallel radiograph [ 10% of 21 mm is
2.1mm]
3- Modified parallel technique :
To overcome the 10% magnification caused by the parallel technique → increase vertical
angulation by 15 ° [ to shorten the image slightly]
Angle Parallel
bisecting technique
technique
Positioning devices:
1- Film holders [ Rinn XCP]
A. most accurate
B. easy to use – no hands needed
C. positions the beam correctly and holds the film
D. no film distortion or bending
E. reproducible image over time
2- Styrofoam biteblock
3- hemostat with a bite block
** pt’s finger causes the most bending of the film → least accurate

Film sizes:
Size 1 Narrow arches and anterior teeth

Size 2 Standard size for PA
Size 4 Occlusal views
** PA lesions are always smaller on radiographs
• infection will be present for at least 3-4 months before a PA radiolucency develops
• Whenever there is a radiolucency = there is an inflammation , no radiolucency there might still
be an inflammation and the radiolucency did not form yet
Tube shift techniques

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

Endodontic instruments
FDI classification
Group I Hand use only: K files, H files, reamers, broaches
Group II Latch type engine driven [ like group I but attached to a hand piece]
Group III Latch type engine driven drills and reamers [ peso reamer, Gates Glidden]
Group IV RC points [ Gutta percha, silver points, paper points]
Hand instruments: [ numbered from 10- 100]

• The number represents the diameter of the instrument in [1/100 of a mm ] at the tip
• Working blade in any size is always 16 mm extending from D1 [ the tip ] to D2 [ 16 mm away
from D1]
• Hand instruments have a constant increase in taper of 0.02
mm per mm of length [ every 1 mm away from the tip has a
taper greater by 0.02mm → Diameter of D2 is greater than
diameter of D1 by 0.32 mm
• Tip angle = 75 ± 15°
• Available lengths = 21,25,28,31 mm
• Hand instruments are color coded
[Number represents the diameter of the tip
in 1/100 of a mm ]
Instruments for pulp removal
Broaches Rasps
has barbs – used to remove the pulp have smaller barbs compared to broaches

Instruments for cleaning and shaping the canals

Reamers K file H file
Used by: Used by: Used by:
• Insert – twist to ¼ or • Insert – apply pressure • Insert – apply pressure against canal
½ turn then withdraw against canal wall – wall – withdraw the file while
• Less flutes than a file withdraw the file while maintaining pressure
– but same cutting maintaining pressure • Flutes that look like successive
efficiency [ because • Stainless steel wire that triangles on top of each other [
more spaces between is triangular or square in Christmas tree] – cut only when the file
the flutes → better C.S that is twisted to is withdrawn [ because the edge faces
debris removal ] form the file the handle of the instrument]
• Remain self centered Aggressive cutter but lack flexibility and
in the canal → less break easily
chance of canal
transportation
Lentilospiral: latch type attachment – used to carry Gates Glidden :

the sealer into the canals
• Flame shaped cutting point – latch type
Peeso Reamer : attachment to a slow speed hand piece – set
of 6
• Very stiff - Does not follow canal curvature and • Used for :
may cause canal perforation A. Coronal flaring of the canal
• Used for : B. Removal of GP
A. Preparing space for a post C. Preparing space for a post
Nickel titanium instruments: NiTi

1- Very good elasticity and resilience
2- Shape memory
3- Corrosion resistance
• Visual examination is not a reliable method to evaluate NiTi files because they can break without
any signs of permanent deformation or unwinding – to reduce this risk Bend the file at least 80 °
to see if the instrument breaks every time before you re- insert the file
spreaders: used to pack GP [ sizes from 15-45]
pluggers : diameter wider then spreaders – blunt end


Endodontic procedure
Acess cavity
The objectives of an ideal access cavity: [ how good your access cavity determines how
good the RCT will be]
1- Gives straight line access to the apical foramen [ unobstructed view of the canals]
The files should pass into the canal without touching any of the walls of the access
cavity
2- Remove the entire roof of the pulp chamber so the pulp chamber can be debrided
3- Conserve as much tooth structure as possible
- Cemento dentinal junction: where the cementum meets the dentine
usually 0.1 mm away from apical foramen.
- Isthmus: a narrow communication between 2 canals [ can be complete
or incomplete]- contains pulp tissue and acts as a harbor for bacteria →
has to be cleaned
Canal configurations
Type 1 Single canal from the chamber to the apex
Type 2 Two canals leaving the chamber but exiting as one canal
Type 3 Two canals leaving the chamber and exiting as two separate foramina
Type 4 one canal leaving the chamber and exiting as two separate foramina
Extra canals are mostly found in :
• Upper molars mostly have MB2 Dilaceration: extreme

• Lower molars can have extra distal canal curvature of the root
• Mandibular incisors and premolars can have 2 canals

ACCESS CAVITY DESIGN:
1- Before access – remove all defective restorations and caries -you can also check the depth
of the preparation by aligning a bur next to a radiograph
2- Walls of the pulp chamber are flared to give a funnel-shape with larger diameter
toward occlusal surface
3- Remove roof of pulp chamber completely so the pulp can be debrided completely
– roof is removed in an upward cutting motion
4- Access cavity is either lingual or occlusal never proximal or gingival
5- If you need to gain access through a PFM restoration – use a round diamond bur
to drill through the porcelain then switch to carbide to drill through the metal
To find MB2 canal in upper molars:
Mostly located between the MB and palatal

canals
• Good lighting + dry field

• Look for a groove that extends from the
MB orifice to the palatal surface.
• Use a file # 8 or #10 to search for the canal
in this groove [ many times the canal will
be hidden by a shelf of dentine that has to
be removed using low speed hand piece]
Special cases
• Extensive restorations:
Ideally the restoration should be removed completely before access cavity- if you prepare the
access cavity through the restoration you will end up with :
1- Coronal leakage [ the restoration loosens because of the vibration during drilling]
2- Poor access and visibility
3- Blockage of the canal because broken filling pieces may get stuck into the canal system
4- Misdirection of bur → perforation
• Tilted crowns:
Sometimes you might need to open pulp chamber without the rubber dam so that the bur can be
placed at the right angulation.
Can lead to [ failure to locate the canals, gouging, perforations, instrument separation]
• Calcified canals:
Use special tips for ultrasonic handpieces -They allow precise removal of the dentin from the
pulp floor – should be done under magnification and illumination
Chelating agents also help in negotiating calcified canals
• Sclerosed canals :
Dyes can be used to located the canal
Ultrasonic tips can be used
Long shank low speed burs can be also used

Working length estimation

Q: why do you need to find the working length ? because it is the length at which canal preparation
and obturation will be done.
Working length [WL] = the distance from the incisal edge or the cusp tip to 0.5 – 1mm short of the
radiographical apex
The apical end of the root canal [ cemento dentinal junction ] is 0.5 -1 mm SHORT from the
radiographical apex but sometimes the foramen is located laterally → more than 1 mm away from
radiographical apex.
Reference point : site on the tooth from which measurements are made [ usually the tip of the cusp
or the highest point of the incisal edge] – must be easily visualized during prep and stable [ does not
change between appointments]
Q: How can you determine the working length?
A> From pre op radiograph
B> Using electronic devices [ apex locator ]
C> Tactile sensation
D> Bleeding on paper point [ in case of open apex]
WL should be measured after gaining straight line access to the canals – pre op WL estimation and
actual WL might be different because much of the coronal deflection will be eliminated [ mostly
length will change in the mesial canals of molars ]
Procedure:
1- Estimate the WL from the pre op radiograph – you should also know the avg length for each
tooth
2- Get a straight line access and place a file to the estimated length with the rubber stopper on
the ref point
3- Take radio graph to verify if the length is correct or needed adjustment
** if file is more than 2 mm away from desired position → adjust and take another
radiograph
Initial size / initial file : the largest file that can go to the full WL [ should have slight
resistance at the apical 3rd ]
Apexlocator: electronic device that has a probe placed on the pt’s lip and a clip that
touches the shaft of a file inserted in the canal. Once the file is closer to the apex
the resistance changes and this is displayed on the monitor. – to confirm if your
reading is accurate you can check the reading with different file sizes – confirm the
length by taking a radiograph.
BEST WL ESTIMATION PROTOCL = APEXLOCATOR CONFIRMED BY RADIOGRPAH
Indications of using an Apexlocator:
1- Pregnant patients to reduce radiation
2- Children who can’t tolerate taking radiographs
3- Disabled or heavily sedated pts

4- Pt’s who can’t tolerate radiograph because of gag reflex

5- Apex is obstructed by [ tori, impacted tooth , shallow palatal vault , zygomatic arch ,
overlapping roots, excessive bone density]
Biomechanical preparation
Objectives of biomechanical preparation:
1- Obtain a continuous tapered conical form that mimics that natural shape of the canal
2- Remove all necrotic tissue, pulp, bacterial toxins from the root canal space
3- Provide enough space inside the canals for irrigation solutions and intracanal medications
• Outline form : the RC prep should be wider coronally than the middle and apical parts
• Retention form : provided by the master cone tug back apically
• Resistance form : provided by keeping the apical constriction as narrow as possible – to prevent
overfilling
• Extension for prevention : to locate any additional canals and remove all pulp debris
Instrumentation Motions:
1- Filing = push and pull
2- Reaming = push rotate pull
3- Watch winding = file rotated 2- 3 quarter turns clockwise then anticlockwise then retracted [
most useful for initial canal negotiation]
4- Balanced force = with flex O and Flex R files – insert with quarter turn clockwise + apical
pressure and cutting with counterclockwise rotation with apical pressure
Instrumentation techniques
Instrumentation techniques
Apical – coronal Coronal – apical
Step back Step down
Roane [ balanced pressure ] Double flared
Crown down
Hybrid
Step back technique [ telescopic preparation] :

Phase I [ apical preparation]:
Start with the initial file [ the largest file that goes to the full WL] then enlarge 3 sizes to reach the
master apical file [ MAF] – in between each file recapitulate by inserting a small size file and
removing the debris.
**All the 3 files reach the full working length

Phase II [ preparation of the remaining of the canal ]

After reaching the MAF enlarge the file size 3 times while reducing 1mm with each size to get the
continuous taper of the canal.
Ex:
• WL = 20 mm initial file is 15
• you enlarge with 20 then 25 then 30 – 30 will be the MAF [ all of those files will reach the full
WL ]
• Enlarge with file 35 [ WL = 19 ] file 40 [ WL = 18 ] file 45 [ WL = 17 ]
Advantages Disadvantages
Good apical stop File tends to straighten in the canal
Good coronal flare Loss of WL
debris can block the canal
Crown down technique [ pressure less technique] :
• Coronal flaring with gates glidden then incrementally remove dentine from coronal to apical area
• Start with large k – file [ ex: size 60 ] with reaming action and no apical pressure , then use
sequentially smaller files as you proceed apically
• Take radiograph when you reach estimated WL
https://www.youtube.com/watch?v=qfBYMA2_evQ
Balanced force technique : [ Roane technique]
• Coronal and middle 3rd are shaped with Gates Glidden , apical part Is shaped by hand files
• Position and pre load the instrument [ engage the dentine] with clockwise rotation then cut and
shape with counterclockwise rotation while maintaining apical pressure [otherwise the file will
come out]
• The apex is prepared much larger than all the other techniques
https://www.youtube.com/watch?v=AbxfYJFRB2A
Q: what are the problems that can occur during instrumentation?
1- Loss of working length → due to canal blockage with debris if you
don’t recapitulate in between files
2- Ledge formation → not following thr canal curvature or
precurving the files
3- Zipping [ widening the apex ]
4- Stripping [ lateral perforation]
5- Over instrumentation [ instrumenting beyond the apex and injury
to the PA region]
6- Over preparation [ widening the canal prep too much ]
7- File breakage
Niti files cause less canal transportation and ledge formation.

Irrigation
Importance of irrigation :
1- Flush out bacteria and debris that form from bio mechanical preparation out of the canals
2- Lubricates the canals during instrumentation and increase efficiency of files / instruments
3- Remove debris from lateral / accessory canals/ fins / deltas and other areas files can’t
reach and clean
4- Dissolves necrotic tissue / pulp remnants and remove smear layer
5- Use solutions that have antibacterial properties to improve sterilization of canals and overall
success of the RCT
Ideal irrigant solution:
1- Should have broad spectrum antimicrobial properties / inactivate bacterial endotoxins
2- Ability to dissolve necrotic tissue or debris
3- Good lubricant
4- Low surface tension to flow into inaccessible areas
5- Dissolves the smear layer
• 5.25% NaOCl has better tissue dissolving capacity
• warming NaOCl syringes in a water bath at 60-70°C → increases it’s effectiveness
Q: how can you check if the canals are clean or
not yet?
Place a gauze near the access cavity and irrigate
then check the gauze to see how clean the
solution is and if there are any debris.

IRRIGATION SOLUTIONS PROPERTIES

SODIUM • Oxidizing action
HYPOCHLORITE [NAOCL] • Degrades organic matter [proteins and lipids]
• High PH = 12
0.5 % - 1 % = • Easily miscible with water and gets decomposed by light
ANTIBACTERIAL • Pale greenish yellow liquid with strong odor of chlorine
PROPERTIES
• No difference between 0.5% and 5 % NaOCl in terms of anti bacterial activity
• Does not remove smear layer
3 main reactions:
5% = TISSUE
DISSOLUTION - Soaping of lipids
- Neutralization of amino acids
- Chloramination
Preferred concentrations of NaOCl:
For antibacterial effect → low concentration [ 0.5 – 1 % ]
For necrotic tissue dissolution→ higher concentrations [ 5%]
** pretreatment with Ca(OH)2 can enhance tissue dissolving capacity of NaOCl

** combination of 5 % NaOCl + EDTA → better anti bacterial properties +
removal of Smear Layer
CHLOROHEXIDINE [CHX] • Alters the bacterial cell membrane - low concentrations it is bacteriostatic, at
higher concentrations is bactericidal
2% • Excellent antimicrobial properties but no protein dissolving properties
• Does not remove smear layer
• High substantivity [ antimicrobial action remains for a long time ]
• Less effective compared to NaoCl
• Stains canals and teeth
** if you mix CHX with NaOCl → better antibacterial effect
** increases effectiveness of Ca(OH)2 when combined as a dressing.
EDTA • Little/ no bactericidal effect

• Used in conjunction with NaOCl effectively removes smear layer
• Used before dressing the canal and before obturation
MTAD • Doxycycline [ABX] + citric acid + Tween 80
• Best bactericidal activity [ more than NaOCl and EDTA]
• Removes smear layer + open DT and allow antimicrobial agents to penetrate
the entire root canal system
• Doxycycline has high binding affinity to dentine providing long antibacterial
effect [ main difference compared to EDTA]
• Effectiveness of MTAD increases when low concentrations of NaOCl are used
as an irrigant followed by a final rinse of MTAD
Best protocol is using 1.3% NaOCl as an irrigant followed by final rinse with MTAD

Ultrasonic irrigation :
• more effective bacterial elimination by causing acoustic streaming + scrubbing effect

• Files must be small and loose to achieve optimum cleaning with ultrasonic vibration
1- Effective removal of smear layer 1- Unpredictable
2- Effective removal of debris 2- Can lead to excessive cutting of the
canal wall
Smear layer = a loosely adherent layer the forms on the canal walls after instrumentation consists of
dentin debris, pulpal tissue and microorganisms – can penetrate slightly into the Dentine tubules.
Smear layer has to be removed because :
1- Harbors micro organisms and allows their proliferation
2- Can cause microleakage
3- Interfere with the physical properties and the adaptation of the sealer
Proposed irrigation protocol:
1- EDTA gel and NaOCl irrigation during canal prep
2- Smear clear for 1 min
3- Intracanal medication
4- CHX irrigation then smear clear before obturation
Intracanal medication
Q: why do we place intracanal medications? Mechanical instrumentation + irrigation alone removes
only 70% of bacteria in the canals . Intra canal medications are placed in between appointment to:
1- Destroy bacteria that remains inside DT, lateral canals , ramifications and fins. And prevent
their growth
2- Prevent bacterial contamination in between appointments
3- Help in managing weeping canals
4- Control inflammatory resorptions
Ideal intracanal medication:
1. Effective germicide and fungicide with prolonged antimicrobial effect
2. Remain active in the presence of blood, pus etc
3. Should be non irritating to the tissue and does not interfere with healing of PA region
4. Should have low surface tension and remain stable in solution
5. Reduce pain and induce healing

INTRACANAL MEDICATIONS
Ex: CMCP
• Dressing of choice for infected teeth
PHENOLIC COMPOUNDS
• High level of toxicity
• Antimicrobial activity might not last very long
• Palliative effect – because it inhibits prostaglandins synthesis and
ESSENTIAL OIL [ EUGENOL ] nerve activity
• High doses are toxic and irritating to PA tissue
• Formaldehyde / glutaraldehyde
• Potent disinfectants
• Cytotoxic & carcinogenic
ALDEHYDES • Formacresol = formaldehyde is the main ingredient – most widely
used medication for pulpotomy
** paraformaldehyde is a component of endomethasone obturating
material – it decomposes slowly to give out formacresol
Chlorine = active ingredient of NaOCl
HALOGENS
Iodide = potassium iodide
QUATERNARY AMMONIUM Ex: Biocides = chemicals that can inactivate a variety of microorganisms
COMPOUNDS
• PBSC paste [ ABX that contains Penicillin , Bacitracin, Streptomycin,
Caprylate ] – no longer used because it caused allergic rxn
ABX + CORTICOSTEROIDS • Ledermix ** [ ABX + corticosteroid ] =
Tetracycline, demeclocycline HCl+ triamcinolone acetomide in a
polyethylene glycol base
• Antiseptic action because of it’s high PH = 12.5 – it has antibacterial

effect as long as it’s PH remains at high levels
• Ca(OH)2 can easily be buffered by dentine and lose it’s antibacterial
effect
• Effective against dead bacteria that might remain in the canal and
CALCIUM HYDROXIDE can still cause and infection
CA (OH)2 • Used when you expect long delay between appointments because it
is effective as long as it remains in the canals. But it can cause
calcifications inside the canals – has to be changed every 3 weeks
• Inhibits root resorption and stimulates PA healing
• E. faecalis = fairly resistant to Ca(OH)2
**Most common bacteria associated with endo failure = e.faecalis [ can survive at low PH and high
temp and withstand starvation + forms biofilms inside canals ]
Weeping canals: a constant reddish or clear exudate associated with radiolucency . the tooth might
be asymptomatic or TTP, next appointment exudate stops and then re appears again in the
appointment after.
Management: dry the canal with paper points then place Ca(OH)2 → next appointment the canal is
dry and ready to obturate
Q: how are intracanal medications applied?

A. Intracanal medication on a cotton pellet is placed inside the pulp chamber and over it a
sterile dry cotton pellet and sealed with temporary filling.
B. Paste intracanal medications → inject with a long narrow tip inside the canal then use a
lentilospiral to spread the medication inside the canal
Temporization Patient can still exist in a

Good endo but poor coronal restoration will have higher failure than poor state of chronic
endo with good restoration. inflammation without
measurable symptoms
Temporization material requirements:
Complete healing occurs
1- Seal the access cavity against saliva and bacteria
2- Have acceptable esthetics and strength only in a small % of cases
3- Easy to apply and remove
Placing a cotton pellet over the canal orifice is controversial:
- Allows you to remove the TF without the risk - Reduce the thickness of the temporary
of removing un necessary tooth structure or material
perforating the pulpal floor - Act as a cushion under the temporary
material → compromise the stability of the
- Prevents blockage from the TF debris going restoration
inside the canal - Increases risk of leakage into the canals
- Might compromise the adaptation of
temporary materials
• Cotton pellet should only be placed over the canal orifice and not the pulpal floor
• Temporary material should have adequate bulk , place it in small increments and properly
condense it – finish the margins and adjust occlusion

Temporization of an access cavity done inside tooth structure

Zinc oxide/ calcium 1- High coefficient of thermal expansion → expands and has
sulphate excellent sealing ability
preparations 2- Low compressive strength [ needs sufficient bulk ]
[ Cavit – coltosol ] 3- Easy to place and remove
** cavit G & cavit W = vary in their resin content and their
hardness
Zinc oxide eugenol Plain ZOE is less effective than cavit

preparations Kalzinol = ZOE reinforced with 2% polystyrene polymer to
increase it’s compressive strength
IRM = ZOE reinforced with polymethyl methacrylate

- better compressive strength + abrasion resistance
- Eugenol prevent bacteria colonization in case of
leakage
** comes as capsules used with amalgamator
GIC 1- Chemical adhesion to tooth structure → very good sealing ability [ used when you
need to temporize for a long time]
2- Fluoride release → anti bacterial
** difficult to distinguish GIC from tooth structure during removal
** fuji VII – has pink color [ easy to identify]
Composite resin [ Single component light cured resin [ UDMA]
TERM – temporary No antibacterial properties
endodontic High hardness , compressive and tensile strength + good marginal seal
restorative material ]
Temporization of an access cavity within a restoration

Restoration type Temporization material you can use
Amalgam Cavit or IRM
Zn phosphate or Zn polycarboxylate should not be used [ they provide poor seal]
Composite ZOE or Cavit
Gold Cavit or IRM
PFM crowns Cavit or IRM
If you doubt the seal and the integrity of the primary restoration it is better to remove it entirely and
replace it
If the final restoration is going to be resin:
• Don’t use ZOE , eugenol will compromise resin polymerization [ cavit and IRM can be used]
• Use total etch adhesive systems [ the phosphoric acid will remove any remnants]

Temporization of a badly broken down tooth:

1- Composite / GIC
2- Provisional crown
3- Temp post + crown [ only when custom post + core is needed]
A. If the tooth is indicated for fiber post → restore ASAP
B. If the tooth is indicated for custom post → place temp post + crown [ for as short
as possible because they have significant leakage]
Temporization for walking bleach:
After placing the bleaching agent, all cavity walls should be cleared of the material and access is
temporised with [ Polycarboxylate cement or ZnPO4 or GIC or IRM or Cavit atleast 2mm thick ]
The gas release inside the chamber may result in the loosening or displacement of the temporary
restoration
Temporizing after apexification / root resorption treatment : composite or GIC [ you can place cavit
directly over the orifice to easily identify the access later and avoid unnecessary loss of tooth
structure]
Obturation
Poor obturation = a major cause of endo failure - Poorly obturated teeth are mostly poorly prepared
• Dressing of Ca(OH)2 is required for at least a week for all necrotic teeth
• Single visit endodontics can be done if the tooth is vital
Q: why do we obturate the canal? If we leave the canal empty → bacteria and fluid will ingress from
the PA region and grow inside the canal again → re infection [ in an ideal environment]. That’s why
we need to create a fluid tight seal of the apical foramen, the oral cavity and the canal walls to
prevent ingress of bacteria and tissue fluid.
We obturate to the apical constriction only → to encourage apical healing
Q: when can you obturate?
1- Pt is asymptomatic [ no pain, swelling . TTP]
2- TF is intact and no communication between canals and oral cavity
3- No foul smell of the canal
4- Canal is dry with no exudate
Ideal obturation material :
1- Easy to introduce into the canal and easy to

sterilize
2- Seal the canal 3 dimensionally and
dimensionally stable
3- Impervious to moisture
4- Radio opaque
5- Biocompatible and non irritating to the PA
tissue

Obturation materials
Gutta Percha [ semi • Basically dried plant extract – similar to natural rubber
solid ] • 3 phases:
A. Alpha = runny, tacky, sticky
B. Beta phase = solid, compactible and elongatable
C. Gamma phase = unstable form
** expands when heated and shrinks when cooled
Can show some tissue irritation because of the high content of Zno
Types:
1- Solid core [ standardized or non standardized ]
2- Thermo mechanical compactable GP
3- Thermoplactized GP
4- Medicated GP
Advantages: Disadvantages:
1- Compactible 1- Lack of rigidity – bends easily and
2- Dimensionally stable cannot be used in small canals
3- Inert 2- Easily displaced by pressure
4- Radiopaque 3- Lacks adhesive properties
Silver points [ solid ] Advantages: Disadvantages:
Rigid – can be used in narrow curved Not good sealing
canals Corrosive products
Not easy to remove
Pastes [ ZOE, calcium Advantages: Disadvantages:
hydroxide , resin] Easy to use Some pastes are toxic
Fills irregularities Some pastes dissolves over time
Acts as lubricant Poor seal
Q: how do you sterilize GP? immersed in 5.25%of NaOcl and then rinsed in H2O2 or alcohol.
Q: how do you dissolves GP? Chloroform or eucalyptus oil
Sealers
1- Fills the space between GP and the canal wall to provide 3D obturation
2- Fills accessory canals and small irregularities
3- Lubricant that aids in the seating of the GP
Types of sealers:
All sealers exhibit toxicity until they set, so
1- Zinc oxide
2- Calcium hydroxide extrusion should be limited as much as
3- Glass ionomer possible.
4- Resin
Sealer placement: lentilospiral OR with a clean file OR coating the master cone
AH plus sealer : Mix to thick, creamy consistency which breaks when spatula lifted 1.5 - 2.5 mm
above the glass slab. Has long setting time so you can mix it early in the appointment

Obturation techniques:
1- Cold lateral condensation If GP too short :
2- Warm lateral condensation
3- Warm vertical condensation Recheck working length and check for
4- Thermo plasticized GP debris that might be blocking the
5- Single point obturation apex or file again and recheck the GP
Cold lateral condensation : Insert master cone [ same size If GP too long:
as master file] – insert spreader [ spreader should reach
full WL or 1-2 mm shorter ] – use the spreader to displace Cup off the tip of the GP or try a
the GP laterally and make space. Remove spreader and larger GP
place accessory GP

Clinical endodontics
1- Medical history and CC [ you need to know if the pain is odontogenic or non odontogenic ]
** non odontogenic pain:
A. Pain without a local cause [ pt tells you this tooth is painful but the tooth is perfectly
intact]
B. Burning, continuous, non variable pain
C. Pain persists over months or years
D. Spontaneous multiple teeth are painful
In general there is no actual contraindication for RCT, however there is limitation in 2 cases :
A periapical lesion [ source of infection] in :
A. Pt on immune suppressants [ specially kidney transplant patients]
B. Pt going to have cardiac surgery [ there is risk of infective endocarditis]
In a kidney trans plant pt if the tooth is vital → do RCT but if there is a PA lesion → extraction
2- Examination [ soft and hard tissue ] + clinical tests + radiographs
• if there was an endo perio lesion : if the primary cause is endo → better prognosis
• If the pt cannot identify which tooth hurts → give inferior alveolar nerve block if the pain
disappears the offending tooth is in the lower arch, if not it is in the upper arch . or if two
adjacent teeth have pain and you can’t Identify which one to access → give LA to one tooth →
pain subsides → access this one if not you access the other tooth
Q: differential diagnosis of a well-defined PA radiolucency associated with a VITAL PULP?
1- Traumatic bone cyst
2- Developmental bony defect
3- Periapical cementoma
4- Early ossifying fibroma
Preoperative radiographs allow you to:
1- Identify any PA pathology
2- Identify pulpal anatomy + number and curvature of the roots and canals
3- If you have patent canals or calcified canals
4- If there is a sinus tract that is traced by a GP – a radiograph allows you to know the source of
infection
5- Orientation of the tooth [ to know how you need to orient your burr during access and avoid
perforation ]
6- Length of the root [ helps you know if you need to adjust your needle during LA]
After taking the pre operative radiograph - estimate the distance between the occlusal surface and
the pulp chamber [ usually in molars if you are 7 mm deep that means your bur is in pulp chamber
→ start looking for the canals horizontally]

Anesthesia
General rule:
• Vital tooth / TTP / anxious pt → give LA

• non vital tooth → better not to give LA [ you want the pt’s feedback during instrumentation and
WL to make sure you don’t go beyond the apex]
a- maxilla → you don’t need to anesthetize palatally
b- mandible → you don’t need to anesthetize lingual or buccal nerves
if the pt still has pain after LA in the mesial root of a lower 1 st molar → tooth might have extra
innervation from superficial cervical plexus or mylohyoid nerve [ in this case you need to anesthetize
lingual nerve ]
Q: how can you check the effectiveness of your LA? Insert a probe b/w the lateral incisor and the
canine → no pain means your block is effective [ this areas has innervation only from the IAN ]
Q: why do u need to give LA in every session? Pulp has complex anatomy and there might be pulpal
remnants that can cause pain during insertion of the spreader , irrigation or filing .
Caries removal + access cavity
Caries removal is done to:
1- remove the source of infection [ if you place TF over caries there will be microleakage]
2- you will know if the tooth is restorable or no
caries removal is always done by a hand excavator not by hand piece. [ you can widen the cavity with
a bur then remove the caries with a hand excavator -done from periphery towards the center to
decrease microbial contamination of the pulp]
You always perforate the pulp chamber above the widest canal [ distal in the lower molars and
palatal in the upper molars ] because :
1- it is easier to feel the bur drop
2- it is the last canal to calcify
• if you can’t locate the canal in an anterior tooth → move the but more palatally to avoid
buccal perforation
• If the pt still has pain you can give intrapulpal injection [ before pulp extirpation] – if you give
it after pulp extirpation it is useless.
If the tooth has a class 2 → build the wall and change it to class 1 so you can place the rubber dam
better and the wall will help keep the irrigation inside the canals during instrumentation
Importance of de roofing in access cavity :
1- Remove all pulp tissue [ if pulp tissue remains it can cause tooth discoloration later on or
infection ]

2- Obtain straight line access – otherwise the files will be bent and they can break
inside the canals or cause apical transportation or ledge formation.
3- Make sure you don’t miss any canals
** finding the canals does not mean you have completed de roofing.
Errors in access cavity:
1- Gouging : you miss the direction of the pulp chamber [ but still a perforation did
not happen]
- Gouging of the labial wall → due to failure to recognize the lingual inclination of the
tooth
- Gouging of the distal wall → due to failure to recognize the mesial inclination of the
tooth
2- Perforation
3- No straight line access [ insufficient de roofing ]
4- Missed canals
Dentine map: darker dentine that connects the orifices of the root canals.
After access cavity → identify number of canals and irrigate
RCT should start and end with irrigation - You should irrigate before starting instrumentation
Widen the orifice with gates glidden [ this is needed in manual instrumentation and lateral
condensation technique] – no need to widen the orifice if you are using rotary
Opening the orifice with GG allows better obturation and sealing
Working length estimation
• Estimated WL → apex locator

• Actual working length → apex locator reading + PA radiograph
Use different files for different canals [ K and H files ] – repeat the radiograph if the file is more than
2 mm away from the apex
Q: how can you avoid false readings of the apex locator?
1- Irrigate the canals then use high volume suction [ the canal should not be very wet or very
dry]
2- Select the suitable file size [ usually size 10 or 15 ]
3- Push the file until the monitor shows it passed the red line and then slightly pull it back by
0.5 -1 mm
Bio mechanical preparation
Oval canals [ mostly in lower premolars and upper second PM ] → treat as if it is 2 canals to ensure
sufficient cleaning
Q: how can you know that a canal is curved ? insert a size 10 file [ very flexible] and place the notch
on the rubber stopper towards the buccal surface – you can know the location of the curve in
relation to the buccalsurface - If the canals are curved → pre bend the files [ starting from size 20]

Initial file = the largest file that can reach the full working length
Instrumentation:
Step 1 : Standardized technique : you treat the entire canal as one piece [ prep is done all over the
length of the canal] – motions : filling , watch winding, ¼ turn and pull
You enlarge 3 size after the initial file [ all will go to the full working length] – the file that is 3 size
bigger than your initial and goes to full WL [ master file]
EX: If your initial file is 20 you need to enlarge 25,30,35 . but when you insert 25 it will be a little
shorter than 20 so you need to do watch winding motion with apical pressure to reach the full WL. [
if you don’t do this → ledge formation ]
It is not a rule that you should enlarge by 3 files [ if the canal is narrow you enlarge by 4 or 5 files
and if the canal is wide → enlarge only by 2 files]
Step 2 : step back technique : enlarge 3 files bigger – none should reach the full WL – if MAF = 35
and Wl = 20
• File 40 should reach 19 mm

Q: when BMP considered completed ?

if the file goes to the full WL but the
1- Irrigate the canals and receive the irrigation
master cone is short → this means the
by gauze [ the color should be clear]
canals are not prepared enough → re
2- You should feel that the canals are smooth
insert the MAF and file a little bit until the
and clean and the MAF should reach the WL
MAF reaches the full WL passively
passively
Q: what can you do if the MAF size 30 doesn’t reach the full WL passively? You can file with a larger
file 35 and 40 with force then size 30 will go passively.[ this does not change the MAF it is still 30 –
because it is the one that goes passively]
Irrigation : ** you should irrigate in between every 2 files
• Irrigants should be delivered deeply into the canals [ insert the fine needle until you feel
resistant then withdraw by 1mm ] - don’t inject when you feel resistance this could push the
irrigant beyond the apex
• Irrigation should last 30 mins

• Irrigants mechanically clean the canals by removing the debris and also clean the canals
chemically .
Chemically non active solutions Chemically active solutions
Sterile water NaOCl [ antibacterial + tissue solvent]
Physiological saline CHX [ anti bacterial]
Anesthesia solution H2o2 [ oxidizing agent]
EDTA [ chelating agent ]
Combinations :
• NaOCl + CHX → brown precipitate

• NaOCl + EDTA → no discoloration [ but they inhibit each other ]
• NaOCl + citric acid → white precipitate that becomes cloudy after shaking
• EDTA + CHX → cloudy blue
If you are using different irrigation solutions you need to separate between them by using
saline.
Q: how can you improve the efficacy of NaOCl? Warm the syringes at 60 ° C + use US tips [ passive
ultrasonic irrigation]
Final irrigation protocol : NaOCl for 1-3 mins → saline → EDTA → saline [ do not use NaOCl again
before obturation → this can lead to dentine erosion ]

Accidents in root canal preparation

MISTAKE CAUSE / NOTES
LOSS OF WL Blockage , ledge formation, broken instrument
OVER The file went beyond the apex → irritation to the peri apical region [ mostly
INSTRUMENTATION because of inaccurate WL]
OVER Canal walls are very thin – too much of the tooth structure is lost [ can be
PREPARATION because GG was used to prep the canals]
LEDGE Using files without pre curving – debris will fill the apical
part and the file will go to a new WL
ELBOW You pre curved the file in the wrong direction → a ledge in the curvature
area → wide area before the apical constriction [You still have only one
apical foramen ]
Corrected by proper irrigation then using injectable GP or warm
condensation technique
** this widening is very difficult to clean + there will be lack of apical seal
APICAL If an elbow or ledge forms and you continue preparation
TRANSPORTATION → you will end you having 2 apical foramina
APICAL A new apical foramen forms but without ledge or widening before the
PERFORATION constriction [ 2 apical foramina are present]
ZIPPING If an elbow or ledge forms and you continue preparation
→ widening of the apical foramen
Q: how can you avoid mistake sin root canal prep?

1- Select clear ref point + always observer the rubber stopper
2- Pre curve files when needed
3- File all walls
4- Always irrigate and recapitulate
5- Don’t rush to bigger sizes
6- Check the length of the file before every insertion [ the rubber stopper might have moved]
7- Discard files that show deformation
8- Remove all previous TF [ leave the cotton pellet until you remove the TF completely to make
sure that no debris goes into the canals]
Excessive filing is usually seen in the mesial walls of molars

Obturation - Tug back provides apical resistance and better sealing + prevents over extension of the
cone
Mastercone is short Mastercone goes beyond the apex
Irrigate and recapitulate or It might be due to Estimate how much of the master cone goes
under prep of the canals → file until MAF goes beyond the apex and cut it off – this way you
passively to full WL ensure that you will have tug back
[ you should put a mark on the cone
corresponding to the ref point before you cut up
the apical part – this point should not change
after cutting]
Using a larger cone → might not go to full WL or

might not have tug back
Mastercone has no tug back → make sure the cone doesn’t go beyond the apex + make sure the
accessory GPs reach the full working length - or you can cut off the apical tip or use a larger cone
that reaches full WL.
Q: how do you determine which size spreader to use?
The biggest size that can reach the full WL or 2mm shorter [ if the WL = 23 mm , appropriate
spreader should reach 23 or 21 mm for the second insertion the spreader should go to 21 mm or
19 mm to be acceptable, if it is shorter by more than 2 mm → use a smaller size spreader ] – with
every insertion of the spreader you can accept 2 mm shorter than the previous length.
Q: what is the correct consistency of the sealer? After mixing and lifting the spatula the sealer should
cut off when the spatula is 1- 1.5 cm away from the mixing slab
Sealer should be thicker in cases of open apex , and less viscous in case of narrow canals or so
many lateral canals [ best is to go for thick sealer in the master cone and less viscous for the
accessory cones]
Accidents in obturation
• Underfiling = less than ideal filling [ along the entire length of the root]
• Short filing= the obturation does not reach the apical foramen
• Poor condensation = the width of the obturation is not correct [ can be due to poor
condensation or under prep of the canals]
• Over extension = the GP is beyond the apex but apical portion is not well condensed
• Over filling = the GP is beyond the apex but the apical portion is well condensed [ you
don’t need to do anything specially if the tooth was vital , the pt will only feel some pain
due to PDL irritation for a few days]


Endodontic procedures- case selection

MEDICAL CONDITIONS AND ENDODONTIC TREATMENT
VALVULAR DISEASE ABX prophylaxis – those pts are at risk of infective endocarditis secondary to dental
AND HEART Tx
MURMUR
• Stress / anxiety can increase the chance of myocardial infarction
HYPERTENSION • Antihypertensive drugs cause postural hypotension
• Give short appointments and LA without vasoconstrictor [ epinephrine]
• Elective endo should be postponed for at least 6 months
MYOCARDIAL • Give short appointments and LA without vasoconstrictor [ epinephrine]
INFARCTION [ MI ] • Minimize stress and anxiety [ because they can precipitate angina]
• If pt has pacemaker → don’t use apex locator [ it will cause interference ]
PROSTHETIC VALVES ABX prophylaxis – those pts are at risk of infective endocarditis secondary to dental
/ IMPLANTS Tx
• Avoid treatment in acute phase** [ check bleeding time and platelet count]
LEUKEMIA • Avoid long appointments
• ABX prophylaxis – pts at risk of opportunistic infections
• Only emergency tx
CANCER • ABX prophylaxis -pts at risk of opportunistic infections due to bone marrow
suppression
HEMOPHILIA , • Avoid aspirin and medications metabolized in the liver
THROMBOCYTOPENIA • ABX prophylaxis
• Pt usually has hypertension and anemia [ check BP before appointment]
RENAL DISEASE • ABX prophylaxis – pt is susceptible to infections
• Screen bleeding time + avoid drugs metabolized in kidneys
• Increased tendency for infection + poor wound healing
• Monitor glucose before appointment [ pt should have breakfast/ normal dose of
DIABETES
insulin]
• Give early morning appointment + have glucose source ready
• Do all elective procedures in the second trimester
PREGNANCY • Only emergencies in 3rd trimester and avoid supine position [ can cause supine
hypotension]
4 things will determine whether you will do RCT or not:
1- Accessibility to apical foramen
2- Strategic importance of the tooth
3- Pt general health
4- Tooth restorability

Endodontic emergencies
• Emergency : situation associated with pain or swelling that
requires immediate attention Regardless of the situation you
• rule of true emergency = only one tooth is the offender. always :
• Emergencies usually affect sleep, working, concentration etc. 1- Determine CC
• Emergencies are associated with pain that started over a 2- Get full medical history
short duration and is un responsive to medication
3- Clinical examination + pulp
test + radiograph
Emergency Clinical presentation management

- Pain If you have limited time →
- Vital tooth Anteriors and premolars: pulp extirpation + dressing
- Radiograph [ RG] = Molars : pulpotomy
Acute pulpitis
normal If you have enough time →
- Caries / large Anteriors / premolars/ molars : pulp extirpation + dressing
restoration
- Pain + TTP + tooth If you have limited time →
feels high Anteriors and premolars: pulp extirpation + dressing
- Vital tooth Molar : pulp extirpation of the largest canal [ palatal in the
Acute pulpitis
- Radiograph [ RG] = upper molars and distal in the lower molars ] + call the next
with apical
normal or slight day to continue pulp extirpation of the other canals
periodontitis
widening of the PDL If you have enough time →
or a small Anteriors / premolars/ molars : pulp extirpation + dressing
radiolucency
Pulp necrosis - Non vital tooth - Pulp extirpation + dressing
Rarely an - No TTP - Non restorable tooth → extraction
emergency - PA radiolucency
- Swelling - Drainage through the canal OR Incision and drainage if the
- TTP swelling is large and fluctuant
** LA infiltration around the periphery of swelling then incise
at the areas of max fluctuance down to the level of bone. –
Acute apical
vertical incision provides better post op healing [ position the
abscess
incision that will aid drainage by gravity]
Keep the wound clean and promote drainage by hot salt water
mouth rinses .
- Systemic complications → ABX
- Access the tooth + instrument the canal + irrigate
- if there is no drainage → instrument beyond the apex to
encourage drainage from PA tissues
Diffuse
- If drainage through the canal fails → I & D + drain
swelling
placement
** CNS changes / toxicity / compromised airway →
hospitalization

• Location of the swelling will depend on : location of the Importance of incision and drainage:
tooth apex in relation to muscle attachments to the
maxilla or the mandible. 1- Drain and evacuate the
bacteria and their toxins
Antibiotic guidelines: 2- Relieve pressure → pain relief
3- Prevent further spread of the
select the ABX with anaerobic spectrum + larger dose for
infection
a short duration
ABX only given for pt’s with systemic manifestations [
fever, malaise, cellulitis, lymphadenitis]
Antibiotics [ if indicated]
ABX Dose
Initial dose 1-2 g then 500mg every 6 hours for 7-10 days
Penicillin VK
Penicillin + metronidazole 250 mg for 7- 10 days
300mg followed by 150 to 300mg every 6 hours for 7-10
Clindamycin
days.
For pts allergic to amoxicillin
Analgesics
Mild pain Moderate pain Severe pain
Aspirin like Ibuprofen 200-400 mg Ibuprofen 400-600 mg Ibuprofen 600 – 800 mg
drug indicated OR + acetaminophen 1000
Ibuprofen 400-600 mg + mg
acetaminophen 650 – 1000
mg
Aspirin like acetaminophen 650 – acetaminophen 650 – 1000 acetaminophen 1000 mg
drug 1000 mg mg + equivalent of codeine + equivalent of
contraindicated 60 mg oxycodone 10 mg

Single visit endodontics

Most studies showed no difference in post op pain and success rates between single visit and
multiple visit endodontics.
Advantages of single visit Disadvantages of single visit

1- Pt comfort [ less visits and less LA] 1- Pt fatigue [ opening for a long time]
2- Saves time [ only one visit] 2- Clinician fatigue
3- Minimizes incomplete treatment 3- Needs experienced doctor
4- Constant WL , you are still familiar with the 4- If a flare up happens it is difficult to
canal anatomy establish drainage
5- Minimizes fear and anxiety 5- Not possible in all cases [ weeping canals,
6- No risk of bacterial leakage in between calcified canals , severely curved canals etc
appointments ]
6- You can’t place intracanal medications [ you
depend only on the action of NaOCl]
Indications Contraindications
1- Uncomplicated cases of VITAL teeth 1- Acute abscess
2- Physically impaired pts that cant come 2- TTP
multiple visits 3- Non vital tooth
3- Medically compromised pts that require ABX 4- Calcified / curved canals
prophylaxis 5- Limited mouth opening [ TMJ pts ]
4- Fractured anterior where esthetics is a 6- Limited accessibility
concern 7- Retreatment cases
5- Un complicated cases of non- vital teeth
with sinus tract [tract because they rarely
flare up + the sinus tract will drain
preventing accumulation of pressure and
pus]
6- Pts requiring sedation
7- Apprehensive but cooperative pts

Latest advancements in endodontics
Advancements in diagnosis:
1- Pulp vitality tests: [ indicate if the pulp has blood flow or not] – more accurate than sensibility
tests [ pulp oximetry, laser doppler flowmetry]
Pulp oximetry:
non invasive – measures oxygen saturation of blood
sensor is modified to be placed over the tooth – detection of a pulse → pulp is vital
**oxygen saturation values from the teeth are lower than the readings from the patient’s fin
ger
No painful stimulus Difficult to find a probe that fits
No previous calibration all teeth
Not affected by age and
physical condition of the pt
2- CBCT: can be –
• Limited ( dental or regional ) - scans only 2-3 teeth -mainly used in endo [ higher
resolution + lower radiation]
• Full ( ortho or facial ) – scans full head and neck
CBCT can be used to:
1- Get more accurate canal measurements
2- Know exact direction of root curvature [ PA will only show mesial and distal curvatures,
CBCT shows buccal and lingual]
3- look for calcified, missed and accessory canals
4- Evaluate fractures/ root resorption/ perforations [a PA will only show mesial and distal
perforations]
Digital impression + CBCT + 3D printing → makes a stent to negotiate calcified canals
without perforations
Advancements in root canal prep :

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

Root canal irrigation: Q: what can you do to improve your

MANUAL : irrigation protocol?
A. Monojet and closed end 1- Use a fine needle [ yellow]
needle designs : prevent 2- Insert the needle deep inot the
irrigants from going beyond
canal until you feel resistance
the apex
then withdraw 0.5- 1mm and
B. Navitip : a small flexible cannula [ only the last 5 mm
is flexible ] that is used to deliver irrigants and sealer irrigate
into the canal – easily inserted into the apical 3rd and 3- Heat NaOCl in a water bath at
curved canals 60°C [ to increase it’s
Needle = closed end antimicrobial and tissue
Navitip FX: smaller than Navitip + the needle is double dissolving effect]
side port [ irrigation goes from both sides] 4- Build the broken walls of a tooth
C. Manual dynamic agitation: after instrumentation and to keep the irrigants inside
confirming tug back – insert the master cone with few 5- Passive ultrasonic irrigation [ PUI]
drops of irrigants and move the cone up and down few [ the energy will warm the
times [ done as the last step before obturation] solution + cause vibrations →
dislodge the debris ]
D. Endobrush: Can’t be used till working length + cause
dislodgement of radiolucent bristle
MACHINE ASSITED :
A. Rotary brushes
B. Quantec – E : continuous irrigation during rotary instrumentation
C. Sonic devices [ frequency below 20 kHz]
D. Ultrasonic devices [ frequency above 20 KhZ]:
Active ultrasonic irrigation: ultrasonic irrigation + instrumentation at the same time [ no
longer used – because when the US tip came in contact with the walls → created more
debris]
Passive ultrasonic irrigation: the tip does not touch the walls
Irrigate then → Place a size 15 K- file inside the canal → touch the file with the US tip [ done
for 20 seconds then change the irrigants – total time 1-3 mins]
E. Endovac system: applies -ve pressure inside the canal – you guarantee that the irrigants
reached the apical 3rd
you irrigate the canal and then insert the cannula , the cannula will apply -ve pressure at the
apical part of the canal [ the irrigation will move from the pulp chamber to the apical part and
then sucked out of the tooth ]
Less PA extrusion of irrigants and less Post op pain
Better irrigation and debridement 1 mm away from the apex
Can relieve pressure from a PA abscess
F. RinsEndo system: applies +ve and -ve pressure cycles inside the canal [ higher risk of apical
extrusion ]
G. Lasers : Co2 & Er: YAG [ effective in melting the smear layer + seal DT] – BUT STILL INFERIOR
TO NaOCl IRRIGATION

Cleaning and shaping:

A. Rotary files:
• Patency files: create a space before the use of rotary shaping files – they were invented
to eliminate the use of hand files and reduce their errors.
 faster in creating space for rotary shaping files
 cause less canal transportation • Rotary files = non- active tip
 more suitable for curved canals • K file = active tip
 can compensate for the lack of experience resulting in
• Second generation patency
more conservative shaping
file = semi active tip
first generation patency files [ path file]: 3 sizes ( 10,15,20) – constant taper
second generation patency files [ Proglider] : one file , multiple taper with semi active tip – the file is
made from M- wire Niti Alloy [ has reduced cyclic fatigue and more flexibility → can be used in very
curved canals]
** if you are using proglider you need to check WL 2 times [ before using and after using the file ]–
because if the canal is very curved the file can change It’s curvature and change WL
**before using the patency files scout the canal with a size 10 file and obtain WL → use the
patency file to the full WL → reconfirm WL
• Shaping files : need pre existing space, they can’t be used to make space [ you create
this space by using manual files up to size 15 or 20.
**When you are using the hand files to create space, you can still cause a ledge, perforation or
zipping.
Niti – alloy : the material has different properties at different temperatures
Martensite R phase Austenite

At cold temp Intermediate phase At hot temp
Excellent fatigue resistance [ all files now are made at this Excellent shape memory
phase]
Companies either change the Great cutting efficiency , edge
duration of the R-phase or at it fidelity, torque resistance
temp it occurs
• When you see M- Wire it means the martensite ratio is more.
• CM wire = controlled memory wire
• Max wire technology = the file is M phase at room temp and A phase at
body temp – the curves increase in size [ Ex: XP endo shaper, XP endo
finisher]
XP – endo shaper file:
• Max wire technology

• Before using XP endo shaper → prepare the canal to size 15
• Self adjusting
• Since the curves increase at body temp → this ensures that the touch all walls of the
canals → better cleaning

Self adjusting file [ SAF]: flexible and has a hollow core, it adapts itself according to the shape of the
canal + provides continuous irrigation during instrumentation
Single file systems

Full rotation Reciprocating rotation
One shape, One curve, XP endo shaper wave one, waveone gold, reciproc, reciproc blue
Gentle wave system: Prepare the canals to size 15 then insert the sterile handpiece inside the canal
– the hand piece will irrigate [ NaOcl then saline then EDTA for 4-5 mins] + provide high energy
waves that will effectively clean the canals then provides negative pressure to suck the irrigant out.
• Gentle wave system has a very high success rate and does not cause post op pain [
because there is no mechanical instrumentation & no apical trauma + the -ve pressure
will prevent apical extrusion of irrigants]

Rotary endodontics
Gates Glidden burs: [GG]

• 6 sizes [ you know the size from the number of stripes on the shank of the
bur]
• When using GG stripping perforation mostly occurs in the distal wall of the
mesial root of lower molars – this can be prevented by using the GG in a
brushing motion against all walls.
Easy to use Can cause ledges / stripping
Inexpensive Cannot be used in curved canals
Easy to retrieve if it breaks Aggressive + remove a lot of tooth structure
Difficult to seal the coronal 3rd of the canal if
you are using lateral condensation
NiTi rotary instruments:

Similarities Differences
1- All made from same alloy [ Niti] 1- Sizes
New advancement: heat treated alloys → better 2- Taper [ increase in diameter of the file
flexibility and resistance to cyclic fatigue for every 1 mm increase in length ]
2- All need a specific engine motor [ slow 3- Cross section & tip design
speed and controlled torque ] 4- Length of the cutting blade and number
3- All are used in crown down technique of spirals
4- Have non cutting tips
** Rake angle = angle formed between the radius of the file and the cutting edge.
• Cutting edge is exactly on the radius → zero rake angle

• Cutting edge infront of the radius → +ve rake angle [ cutting action]

• Cutting edge behind the radius → -ve rake angle [ scraping action]
Tapers in endo instruments explanation:
Taper = how much the diameter of the file/ instrument increases with
every 1 mm increase in length
• D0 = the tip of the file

• D1= 1 mm away from the tip
Manual files Rotary files
• D2 = 2 mm away
Have only constant taper Can either have constant taper or
[ constant increase in their multiple tapers Hand files have 3 lengths [ 21 mm, 25
diameter, but the increase is Constant taper : [ constant mm , 31 mm ] but regardless of the
small] increase in their diameter , but the length of the file the length of the
Ex: 2% taper means that with increase is large – up to 8- 10%
active part is ALWAYS 16 mm only [
every 1 mm length increase the taper ]
located at D16]
diameter increases by 0.02 mm
4% taper the diameter increases Multiple taper: the increase in In rotary the length of the active part
by 0.04 mm etc.. diameter is not constant is variable but the maximum is 14
Ex: file size 25 with taper 2 % Ex: mm [ located at D14]
what will the diameter be at D3? Taper from D0-D1 = 2% [ diameter
D0 = 0.25 mm increases by 0.02 mm ]
D1 = 0.27 mm Then taper from D1-D2 = 3% [ benefits of multiple tapers:
D2 = 0.29 mm diameter increases by 0.03mm] 1- Increase file elasticity
D3 = 0.31 mm From D2 -D3 = 4% etc.. 2- Increase cutting ability
Reverse taper : the large taper is
3- No need for recapitulation
In hand instruments the taper is at D0-D1and then it decreases as
during prep
small otherwise the friction will you go more coronally
be very high and you can’t use 4- Decrease torsion and
the file. number of files in the system
** we try to decrease the number of contact points between the file and
the canal walls to avoid taper lock which can break the file or the dentine
walls.
Rotary instruments motions

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

Thread tendency :
The cutting edges in the rotary files are continuous helices → this leads to thread tendency [ the
feeling of the file sinking inside the canal when you want to remove it , at this point if you don’t stop
the rotation the file will break ] – Thread tendency is mostly experienced when you are doing beck
motion and the file rotation is full rotation
• If the helicals are placed parallel to each other [ constant helical angle]→ higher thread
tendency
• If the helicals are not parallel [ variable helical angle] → lower thread tendency
 Adv of thread tendency: allows the file to reach the apical part easily
 Disadv of thread tendency: the file can break
Q: why is it better to use rotary files? Q: what are the disadvantages of rotary
files?
1- Faster preparation
2- Provides the desired shape of the 1- Higher risk of fracture compared to k
canal [continuous tapered conical files
form] 2- Might create micro cracks in the
3- Lesser chance of perforations, apical dentine
transportation and zipping 3- Can’t be used in curved narrow
4- Centered preparation canals
4- Don’t clean oval / wide canals very
well. [ fixed by doing brushing
motion]
why do rotary files have less complications? Because they have non active tip + they are made from
nickel titanium alloy [ flexible ]
heated treated niti alloy systems are more flexible and can be used in curved canals.
Rotary files can be used in all RCT cases EXCEPT: narrow canals, C or S shaped canals, oval and
wide canals.
C or S shaped canals : use manual filing and focus on irrigation

Clinical procedure of using rotary systems: ALWAYS FOLLOW MANUFACTURER INSTRUCTIONS

REGARDING TORQUE, SPEED AND SEQUENCES OF FILES
Protaper system [ FULL ROTATION] Wave one [ RECOPRICATING ROTATION]
1- Access cavity + WL estimation 1- Access cavity
2- Insert S1 file [ it is okay if it doesn’t 2- Select appropriate file size
reach the full WL ] Insert a 10 k file
** S1 is used before SX because the tip is If it is stiff or doesn’t reach WL → use
thinner and the file is more flexible yellow wave one file
3- Insert Sx file to prepare the coronal If 10 k file is loose, insert 20 k file→ if it is
part of the canal stiff or doesn’t reach WL→ use red
** if you didn’t take WL you should do it waveone file
NOW. If 20 k file is still loose → use black
4- Use S1 file again [ but now it has to waveone
go to the full WL] **Lubricate the files with EDTA + irrigate properly
5- Use S2 → F1 → F2 → F3 file with NaOCl
**Lubricate the files with EDTA + irrigate 3- Use the files in a crown down technique
properly with NaOCl with beck motion 2-3 times then remove
** small canals you can stop at F1 the file irrigate and repeat
** use each file for max of 10 seconds ** to know if you cleaned the canals well enough-
insert the matching k file to the rotary file you
used.
[ red waveone = 25 k file, black waveone = 40 k
file]
If the k file goes to the full working length
PASSIVELY and has tug back apically→ you are
ready for obturation.
If the k file is loose → go for a bigger file size
Protaper system has 6 files If the K file can’t reach full WL → use the wave
3 shaping files [ Sx, S1, S2] – multiple taper one again in brushing motion
3 finishing files [ F1,F2,F3] – reverse taper Wave one has 3 files
If the file has been used before make sure Yellow = small
you do brushing motion because the file Red = primary size [ used in most cases]
decreases in diameter with use. Black = large
the file moves in one cycle clockwise and
counterclockwise and every 3 cycles completes
one full rotation
** SINGLE USE SYSTEMS = disposable files – if you sterilize them they change dimensions and don’t
fit into a hand piece again. [ files might be contaminated with prions from the pulp tissue , prions will
not be killed by sterilization ] – single use systems reduce chance of fracture
** SINGLE FILE SYSTEM = you can finish the canal prep using one file only

Latest advancements in obturation

If at the time of obturation you saw that the TF is dislodged and there is communication with the oral
cavity → irrigate , place medication and postpone obturation
Obturation techniques
OBTURATION TECHNIQUES
Cannot be used in [ curved narrow canals, internal resorption, canals with irregular
LATERAL COMPACTION shape]
The master cone should have tug back ** [ if there is no tug back the master cone
will move out of the apex during condensation]
Uses a heat carrier [ to warm the GP] and pluggers
Procedure:
Cut the master cone at the canal orifice → heat the heat carrier by any source of
fire and insert it into the coronal part of the canal → use the plugger for the
coronal part then repeat as you go to the middle and apical part using different
WARM VERTICAL
size of pluggers.
COMPACTION [ WVC]
The final plugger should be 5-7 mm shorter than the WL
[ SCHILDER’S
After you achieve good compaction of the apical 3 rd you fill the rest of the canal
TECHNIQUE]
either by the same procedure or using injectable GP / backfill.
ADV: excellent sealing of the canal apically and lateral / accessory canals
DISADV: larger pluggers can bind the canal and split the root + lip burning from the
heat carrier + difficult to master
• Touch’ n heat [ Sybron endo] is an electric heat carrier that was later
invented and reduced the chance of lip burning and the need for
torches
warm vertical condensation but not done by hand instruments it is done using
system B
procedure: Cut the master cone at the canal orifice → in one motion – push the tip
smoothly until you reach the binding point [Heat delivery should stop 2-3 mm
before you reach the binding point by you need to keep on pressing with the tip to
CONTINUOUS WAVE
compensate for the shrinkage that might occur when the heat stops ] → reheat the
[ SCHILDER’S
plugger for one second to release the GP and remove the plugger
TECHNIQUE LATER
After you achieve good compaction of the apical 3 rd you fill the rest of the canal
BECAME CONTINUOUS
either by the same procedure or using injectable GP / backfill.
WAVE]
Binding point = the point of contact b/w the tip and the canal wall
ADV: excellent seal [ including lateral canals] +less technique sensitive + no need
for separate pluggers and heat carriers the tip does the work of both + the tip used
can deliver the exact heat for a long time [ in hand instruments the plugger can be
very hot at first then cool down] + can be used with standardized/ non
standardized / rotary GP
A heated spreader is inserted lateral to the cones → un heated larger spreader is
inserted → insert accessory GP until obturation is completed
ADV: no need for special GP or instruments + Heat is not introduced to apex+
Precise GP length control + Potential for root fracture is reduced
WARM LATERAL
• Endotech – one button heats the tip to warm the GP laterally then
CONDENSATION
another button will cause vibrations
• Enac - the tip only delivers vibrations which are enough to heat the GP
You can achieve the same effect if you touch the side of the spreader with and US
tip → vibrations and heat

Ex: obtura , ultrafill, calamus

Definite apical stop is needed
Indications:
- abnormal canals with many irregularities [ ramifications, C / S
shaped canals ]
INJECTABLE GP - internal resorption
[THERMOPLASTICIZED - back filling of canals after WVC or continuous wave
INJECTABLE procedure: choose appropriate size of tip [ appropriate size is a tip that is 3-5 mm
TECHNIQUE shorter of the WL ] → apply sealer and inject warm GP inside the canal allowing
the back pressure push the needle out of the canal [ do not resist this pressure] →
use pluggers dipped in alcohol [ to prevent it from sticking to the GP] → compact
the GP
• Guttaflow : you inject it inside the canal + you place a master cone [
easier to remove for retreatment and post preparation ]
Compacter looks like a reveres H file
THERMO MECHANICAL
Insert the master cone then insert the compacter into the canal [ the energy
TECHNIQUE
delivered will melt the GP and the threads of the compacter will direct it apically]
MC SPADDEN
DISADV: can’t be used in curved canals the compacter breaks easily + canals are
COMPACTION
usually over filled when using this technique
Ex: soft core , dense fil Consists of a flexible steel, titanium, or
plastic carriers coated with GP
The match between the file and the cone must be perfect – the
kit has a file called size verifier [SV] to verify which size of GP to
use
If the SV fits → use same size obturator
CARRIER BASED If the SV does not fit → use this SV to continue the prep or use
TECHNIQUE a smaller SV
ADV: easy single insertion + excellent seal + quick
DISADV: needs apical stop + can’t be used if you need to place
a post + difficult in case of re treatment
• Gutta core : GP core coated with another type of GP – the core comes
out efficiently & no plastic core remains in the canal [ easier in case of
retreatment]
Indication: very wide canal with open apex
Procedure: many GPS stuck together to form a braided
cone → insert the GPS in [ chloroform, eucalyptol or
halothane ] → the solvent will soften the outside of the
CHEMO PLACTIZIED
GPS → insert the GPS into the canal and take it out
TECHNIQUE
several times [ each time dip it in solvnet again ] untill
you reach full WL → the GP will take the shape of the
canal → clean the GP with NaOCl → apply sealer and
insert

Apical barrier
Q: how can you make an apical barrier for immature roots with open apex?
1- Dentine chips / MTA ( best ) [ permanent solution]
2- CaOH2 [ temporary solution]
Dentin apical barrier: MTA apical barrier:
Proper cleaning and removing of all debris → with GG or a hand file insert the MTA apically using messing
create dentine chips 1 mm shorter than the WL → pack the chips with gun or a special carrier [ better under
a paper point of create an apical barrier of 1-2 mm od dentine chips → microscope]
canal is obturated with a GP over the dentine chips
ADV: biocompatible + can be used in
DISADV: further weakens the tooth + some inflamed pulp tissue might wet areas + bacteriostatic
still be inside the debris
DISADV: long setting time + difficult to
manipulate

Restoration of endo treated teeth

Endo treated teeth are more prone to fracture because of decrease in structural integrity NOT
because loss of moisture. [ there is no difference in moisture content between endo treated teeth
and vital teeth]
Decreased in structural integrity happens because:
1- Loss of tissue [ removing caries, previous restorations, fractures , looking for MB2 canal,
access cavity and canal shaping etc]
2- Changes in flexural strength of dentine caused by irrigation solutions
Q: when should you restore an endodontically treated tooth? Ideally ASAP, but if your doubting the
prognosis of the tooth wait until you see clinical / radiographical evidence of healing then restore the
tooth.
Q: what factors affect your decision of when and how you should restore and endo treated tooth?
1- Restoration material to be placed [ amalgam / composite can be placed after obturation
because they are easy to remove in case of failure – but you should wait until you confirm
healing before placing posts and crowns because they are harder to remove in case of
failure]
2- Quality of the obturation [ if you have poor RCT and poor healing → re Tx , if you have poor
RCT but good healing you can go ahead with a direct restoration but you must re Tx if you are
going to place crowns]
3- Pre existing endo status (Presence / absence of PA changes ) : [ will also guide you whether
you need re Tx or not]
4- Location of the tooth in the mouth [ anterior teeth need to be restored after obturation for
esthetics]
Q: Do you need to crown every RCT tooth? No, crowns are only needed if there is high risk of
fracture of the tooth [ anterior teeth can be crowned to improve esthetics ]
Minimal coronal damage Significant coronal damage

Anterior tooth: Anterior tooth:
Intact marginal ridges Loss / undermining of marginal ridges
Intact incisal edge and cingulum Loss of incisal edge / Fractures
Small proximal fillings Large proximal fillings
Restore the access cavity with GIC 1- Restore the tooth with a filling [ if the
then composite [ GIC will provide structure is retentive enough with
better sealing because it favorable occlusion]
chemically bonds to the dentine + 2- Crown
act as a barrier between the zinc 3- Post + core + crown
oxide based sealer and the 4- Nayyar core
composite]

** make sure that you clean the coronal area from any
GP or sealer to prevent discoloration later on Posterior tooth:
Posterior tooth: lost walls / cusps
Intact walls / cusps 1- Endocrown
1- Direct composite restoration 2- Full crown
2- In lay 3- Post + core + crown
4- Nayyar core
NOTE: if you are placing a restoration in the same session, you can remove the sealer coronally using
US devices or better wait until it dries then remove it
Post and core:

Indications:
1- If the remaining of the tooth structure does not provide sufficient retention for a restoration
2- If the palatal wall of maxillary anteriors is lost [ prevented by making your access cavity more
incisally]
3- If the labial wall of the mandibular anteriors if lost
Common mistake during accessing through a PFM crown is making the access too palatal to
preserve the porcelain on the incisal edge → little palatal wall remains → this will fracture the
dentine core and will lead to loss of the crown [ better to remove the crown before accessing to be
able to place the access cavity more insically and preserve the palatal dentine ]
Endocrown: uses the pulp chamber for retention

Indications Contraindications
1- Inadequate clinical crown 1- pulpal chamber is less than
height 3mm deep
2- Inadequate thickness of the 2- if the cervical margin is less
tooth walls than 2 mm wide for most of
3- Inadequate inter occlusal its circumference
space 3- Long clinical crown height
4- Inadequate ferrule
5- Teeth with very narrow
slender roots [ you can’t
place posts]

Endocrown preparation:
https://www.youtube.com/watch?v=1rFkRIWQaM4
2 mm occlusal reduction → remove undercuts in the access cavity
+make the coronal pulp chamber continuous with the access cavity →
polish to remove irregularities and produce a flat surface
• Use a non abrasive instrument to remove 2 mm of the GP from the orifice of each canal [
this will improve retention]
• Cementation with resin cements [ rely X ]
Nayyar Core: a core created inside the pulp chamber and the
canal entrance
Amalgam: placed posteriorly

Least technique sensitive Poor esthetics – applied only posteriorly
Cheap Corrosion and galvanic shock
Can be condensed into undercuts
Composite resin / GIC : placed anteriorly [ must be covered with a crown]

Esthetics + ease of placement Technique sensitive
Degrades with time
Post and core :
• The only advantage of the post is to retain the crown

• The post weakens the tooth and makes it more prone to fracture + makes re treatment
more difficult
• Fiber posts have similar physical properties like dentine → they can reinforce the tooth
and have less chance of fracture
• Post indications have different classes :
Post is not indicated in class 1 [ 4 walls remaining] and not indicated in class II [ 3 walls
remaining] or III [ 2 walls remaining] if you are using adhesive
restorations
Post is indicated in class IV [ one wall remaining] and class V [ no walls
remaining]
Post indications Post contraindications

when you can’t do and endocrown Small narrow canals , curved roots
when you have one or no walls remaining Alternative : nayyar core + crown anteriorly or
Nayyar core + endo crown/ crown posteriorly

If you don’t have 2 mm ferrule

[ you can obtain a ferrule by ortho extrusion or
crown lengthening]
Ways to obtain a ferrule of 2 mm :

Crown lengthening Orthodontic extrusion
Faster – can be done in one session Takes 2 – 3 weeks
Soft tissue removal : done if you’ll still have at least 1 mm of sulcus
after trimming Contraindicated in:
Bone contouring: if you can’t keep a 1mm sulcus after trimming → 1- short roots
remove bone 2- If the extrusion will
result in furcation
EX: if the pt has 1 mm of crown height and a sulcus of 2 mm → just exposure
do gingivectomy to gain 1 mm of crown height and keep 1 mm of 3- Inadequate prosthetic
sulcus depth space
DISADV:
• Asymmetry of the gingival margin [ should be avoided in
pts with gummy smiles – the asymmetry will show]
• Causes un favourable increase in crown to root ratio
• Can cause damage to bone of adjacent teeth → makes
implant placement harder later on because the lost bone
cannot be regained
Avoid crown lengthening if :
A. Pt has gummy smile → the asymmetry of gingival margin will show
B. You are unsure of the prognosis and the pt might need implants later → the bone lost cannot be
regained and this will make implant placement harder
Procedure of post and core: [ remove GP – prepare space for post – prepare coronal tooth structure]
1- Removal of the GP : 4-5 mm of GP should remain apically
• if you decided to go for post and core while you are doing the RCT:
Do partial root filling – you only fill the apical 5 mm [easier with vertical condensation
than lateral condensation]
You cannot obturate completely and then remove the GP and prepare for the post in the
same session because the sealer has to be completely set before you remove the GP
otherwise it will disturb the apical seal.
• if the canal is previously filled and the tooth is now indicated for RCT:
GP can be removed by :
A. heat :
using heated endo probe / plugger
the tip of a system B or touch n heat device
B. solvents : used only in the coronal part of the canal never apically

chloroform, methyl chloroform, benzene , xylene, eucalyptol oil , halothane
C. hand instruments [ always needed with heat or

with chemicals ]
k file is inserted to create space above the root
filing then GP is removed with H file or S file [ better
because less chance of fracture and safer to use]
D. micro debrider : small files with 90° bends to remove any GP remaining on the walls
on the canal.
E. rotary instruments:
 Gates Glidden : mostly used coronally – inserted for 2-3 mm then pulled out [
it will remove a little bit of GP with it and soften the remaining GP for easier
removal ]
it is also used to create space for hand instruments or solvents
 rotary files that have active tips
The best method to remove GP is US tips under microscope magnification
2- prepare the post space:
• determine the size of the canal
• prepare the space for the post using peeso reamers or parapost drills [ the drill size
corresponds to the post size ]
• place the post inside the canal and check by xray
Factors affecting post retention:
A. post length [ most imp factor]
• the greater the post length the greater the retention and the
better the distribution of forces
• more important than diameter for retention
• should be 1 / 2 to 2/3 of the root length - minimum post length
= the length of the crown
• leave apical seal of 4-5 mm [failure to leave an apical seal →
RCT failure ]
• the post should extend 4 mm apical to the crest of the bone to
decrease stresses in the dentine and in the post [ otherwise
you’ll have fracture of the tooth cervically
• if the canal has a curvature → insert the post up to the point where the curvature starts
B. post diameter:
too narrow → post will fracture

too wide → root will fracture

post diameter should not exceed 1/3 the

diameter of the root [ 1 mm of sound dentine
should be maintained circumferentially]
post designs :
Parallel More retentive but can cause root fracture apically [ because the canal is tapered ]
Taper Can create wedging effect [
focus occlusal forces towards the apical region ] leading to root fracture
Parallel / Parallel coronally and tapered apically
taper
** parallel is more retentive than tapered , threaded is more retentive than cemented – cemented
posts distribute the forces better
Cements : conventional zinc phosphate and zinc polycarboxylate cements have little effect on
retention but if you use adhesive resin cements you can improve retention
Cementation:
1- Dry the canal [ very imp]
2- Place the cement inside the canal and on the post and insert the post with least pressure
• Posts in anterior teeth have higher failure rates because they are subjected to different
types of forces , in posterior teeth the forces are more parallel to the tooth → higher
success rate
Q: what are some common mistakes during post preparation?
1- Disturbance of the apical seal [ you remove all of the GP]
2- Perforations
3- Over enlargement of the canal space
4- Extrusion of the obturation material
5- Separated instrument
3- Preparation of the coronal structure:

Be conservative – remove unsupported tissue [ maintain ferrule effect]
[ cast post = you need to remove undercuts , prefabricated post = no need to remove
undercuts]
Custom made cast post and core needs anti rotational notch
IMP NOTE : post + core are used when you don’t have enough tooth structure to retain a restoration
but you still need ferrule of at least 1.5 – 2mm.
Q: why is the ferrule needed even if you are placing a post and core? Posts cause wedging effect ,
the ferrule will separate between the crown and the post → prevent root fracture
• Posts can be passive → retained only by cementation

• Active → retained by threads engaging into the dentin + cementation
Post Length Minimum same length as clinical crown

Or at least 1 /2 - 2/3 of root length

Post diameter Should not exceed 1/3 root diameter
1 mm of sound dentine circumferentially
Apical seal 4 -5 mm

Bleaching of vital and non vital teeth

Stains :
1- Extrinsic [ good prognosis] – chromogenic bacteria adsorbed into plaque
A. Non metallic stains: coffee and tea, smoking, CHX stains
B. Metallic stains:
• occupational exposures: iron → black stain / copper → green stain
• Dietary supplements: iron supplements should be taken for few weeks then stopped for
few weeks before they can be taken again
2- Intrinsic [ fair prognosis ] – occurs during tooth formation of after eruption [ ex: fluorosis,
tetracycline staining, dentino / amelo genesis imperfecta , enamel hypoplasia , trauma,
obturation material remnant, pulpal remnant, iodine containing intracanal medications
(metapex) ]
3- Age related : due to thinning of enamel + 2° dentine deposition + prolonged exposure to
staining agents
Q: why do traumatized teeth get discolored? Hemoglobin from bleeding breaks down to hemosiderin
and causes staining
Q: how does bleaching work? It is a redox reaction , the bleaching agent gets reduced and releases
free radicals to oxidize the stains
Bleaching agents:
1- Hydrogen peroxide :
Hydrogen peroxide can break in 2 ways:
A. Into water and nascent oxygen [ weak radicals] – in the presence of moisture
B. Perhydroxyl and hydrogen [ strong radicals]
Q: why should the teeth be dry before application of H2o2? To get more perhydroxyl radicals that are
stronger and give better bleaching [ moisture will cause H2o2 to give water and nascent oxygen
which are weak radical and don’t bleach well ]
2- Carbamide peroxide : gives urea which will later give co2 and ammonia [ the high PH of
ammonia is what causes the bleaching ]
Needs to contact the tooth surface for longer time – better tolerated for home bleaching
3 % hydrogen peroxide = 10 % carbamide peroxide
Q: how can you increasing bleaching efficacy?
1- Increase peroxide concentration
2- Increase gel temp
3- Increase duration of exposure to tooth
Overbleaching will increase enamel porosity → anything the pt drinks or eats will cause staining [
management: apply fluoride to remineralize the tooth surface]

Instruct the pt to stop home bleaching when they stop seeing any significant color change [ aim for a
color to match the white in their eyes]
Q: what are the most common side effects of bleaching? Sensitivity then gingival irritation
Q: a pt asks you what is the best home bleaching agent , what do you reply? Look for any product
that has the ADA seal of acceptance
** ADA seal of acceptance means the company did safety studies on the product + at least 2 clinical
trails that showed at least 2 shade difference
Home bleaching : [ gives the best results ]

A. 10% carbamide peroxide in a custom tray [ adding carbapol will extend it’s action for 8 hours
→ can be used overnight]
B. Whitening strips containing H2o2 [ H2o2 action is only 30 mins]
• In the initial stages of bleaching teeth might white spots or too white in general → this
becomes less with time
Q: what instructions do you give to the pt to reduce sensitivity after home bleaching?
Brush with potassium nitrate toothpaste for 2 weeks before bleaching + placing the desensitizing
toothpaste in the tray and wearing it for 30 mins daily for a week before bleaching. Or the pt can use
CPP- ACP desensitizing agent.
Wear the tray with the bleaching agent for 1 hour daily for 2 weeks . [ more than this the teeth will
get porous ]
If the pt is using home bleaching → wait for 1 week after bleaching stops before you place any ortho
brackets or composite restorations [ residual peroxide will interfere with the polymerization of
composite]
If teeth are mal aligned → avoid strips
OTC products - Unless a peroxide is present , the whitening effect is only stain removal
In office bleaching:
1- Liquidam is placed along gingival margin and light cured
2- Bleaching agent is placed and activated by [ laser or light to increase it’s temp and
effectiveness]
** bleaching kits have capsules of vit E , used when there is blanching of the tissues due to
seepage of the bleaching gel under the barrier. Vit E is a powerful anti-oxidant ,it reverses the
soft tissue damage in the gingiva – there is no actual difference in efficacy when you bleach
with / without light [ light is only used because the pt expects it]
Whitening should result in at least 2 shades color change
Best is doing in office bleaching then in home bleaching for 2 weeks
Q: how can you reduce relapse after bleaching?
1- Use power tooth brush + whitening toothpaste
2- Brush / rinse immediately after anything that causes stains

3- Drink beverages that cause stains with a straw

4- Annual touch up with the custom tray
Non – vital teeth bleaching :
Agents used:
• Superoxol [ H2o2 + distilled water] + Sodium perborate [decomposes into sodium

metaborate and hydrogen peroxide and nascent oxygen]
These chemicals are mixed together to a thick paste and sealed into the access cavity
• Thiourea
1- Walking bleach technique:
1- Remove GP to a level below the CEJ
2- Apply barrier over GP [ IRM or GIC or RMGIC ]
3- Place the bleaching agent and seal the tooth with GIC
4- Remove after 1 week
3- Open chamber bleaching: [ internal/external bleaching]:
1- Remove GP to a level below the CEJ
2- Apply barrier over GP
3- Place cotton inside the cavity → pt goes home
4- At home the cotton pellet is removed , the pt injects the
bleaching agent inside the cavity and inside the tray
3- Thermo-catalytic bleaching:
Superoxol placed in the canal + heat application
side-effect: external cervical root resorption

Lasers in endodontics
Uses of laser in endodontics :
1- Acute / Chronic apical periodontitis
2- Periapical abscess
3- Apical resorption
4- Therapy resistant long term failure cases
5- Combined periodontal-endodontic pathology
6- Partly sclerosed canals, where the apex is not reachable because of sclerosis
Commonly used lasers

Nd:YAG Best for canal sterilization - Highest bactericidal action
Laser has good penetration depth – laser can reach the apex
Used to modify the morphology of the root canal and seal the root canal wall [ melts
the smear layer forming a homogeneous surface that seals open DT]
Can be used to remove GP and broken files in cases of re treatment [ less time
compared to conventional methods]
Better for apicectomy – because of it’s coagulation effect
Diode Less penetration depth compared to Nd:YAG
Seals the DT
Stimulates cells proliferation + has inhibiting effect of inflammatory enzymes
Er:YAG Not very suitable for canal sterilization
It’s bactericidal effect is similar to irrigation solutions
Can be used to remove ZOE sealer from canal wall
Procedure : After conventional preparation, extensive rinsing and drying of the canal with paper
points → Laser fibre is inserted into the canal after marking with rubber stop [ fibre does not remain
at the apical stop for more than 1 sec since temp. will rise to critical levels ] → Fibre is pulled from
apical to coronal in circular movements to cover the whole root dentin surface –procedure is
repeated at least 5 times.
Canal is filled with Ca hydroxide and sealed till the next appointment. [ 2 sessions are needed for
optimum laser supported RCT]
In some cases, the bacteria may actually increase after the 1 st visit ,but after the 2 nd session of
irradiation, chemical sterilization is achieved. [ laser will make the bacteria more sensitive to
irrigation → better eradication]
1- Painless 1. High cost of equipment
2- Lesions treated by laser heal faster 2. Large size
3- Create bloodless field + reduce 3. Need for complete knowledge of
contamination equipment, use and safety.
4- Minimizes post-operative swelling, pain
and scarring
Protection against laser : Always wear protective googles, mask and use high speed suction. Avoid
laser contact with water and alcohol

Regenerative endodontics
Immature teeth with open apex problems:
1- Difficult to clean
2- Very hard to get proper apical seal
3- Dentinal walls are very thing & weak → increased risk of cervical fracture
Immature tooth with open apex tx options
Apexogenesis Apexification
done if you still have some VITAL pulp tissue Done if the tooth is necrotic
procedure: Procedure:
1- Do partial pulp extirpation [ leave 4-5 mm of 1- Total pulp extirpation
pulp tissue apically] 2- Apply capping material at the apex – after a
2- Apply capping material [ calcium hydroxide, few months calcified material will form and
MTA, biodentine] close the apex [ you check for closure of the
3- Obturate over the capping material apex by paper points not files ]
** if you placed MTA you can obturate immediately – 3- Obturate over capping
if you placed Calcium hydroxide you material
can’t obturate immediately -because ** if you placed MTA you can obturate
vital pulp tissue remains apically → the immediately
apex will develop ** the apex closes but the canal walls
normally and close [ but the canal walls are still thin and weak.
are still thin & weak]
** both apexogenesis and apexification close the apex but the walls remain thin and weak , the only
option to allow the walls to get thicker is root canal revascularization.
Root canal revascularization

The only technique that can increase the thickness of the canal walls + close the apex + makes
the tooth respond normally to sensibility testing.
Indicated for immature teeth with necrotic pulps
First appointment:
Determine WL → irrigate with NaOCl or CHX
Second appointment: [ after 3-4 weeks ]
Make sure the pt is pain free, there is no exudate and
the canals are dry
Insert a STERILE sharp file and go beyond the apex to
induce apical bleeding until the blood reaches the
CEJ – wait for 15 mins
Apply MTA then GIC
** don’t irrigate with NaOCl in the second session
when you want to induce bleeding.
** the apex has sth called the apical papilla which is rich in stem cells that goes into the canal
when u induce bleeding – after a while pulp like tissue forms to increase canal wall thickness and
close the apex + the tooth will have normal sensibility response


Dental trauma
General rule : not all cases of trauma
need intervention some only need follow
up
NOTE:
When RCT is indicated In a traumatized
tooth and the tooth is still mobile →
access cavity and pulp extirpation will
cause more trauma to the PDL [ if RCT is
indicated pulp extirpation can be
postponed for 10 – 14 days]
Q: why do most dentists make wrong

decisions in dental trauma cases?
1- It is hard to determine the priority and which traumas to treat first since most cases include
more than one type of trauma [ ex: crown fracture + root displacement + alveolar bone
fracture]
2- Trauma is a not sth dentists deal with on daily basis
Because teeth are hard tissues : injuries appear as fractures
Crown fractures : Root fractures : are all Crown/root fractures :

complicated fractures
A. Incomplete = involves only the enamel A. Un complicated = involves the
because you can’t recognize
enamel + dentine + cementum
B. Un complicated = involves the dentine fracture of the dentine if it
B. Complicated = involves the enamel +
C. Complicated = involves the pulp does not involve the pulp
dentine + cementum involves the
pulp
Trauma classification
Crown fractures
Just a crack in enamel / enamel chipped off
Incomplete fracture [ crown Usually no loss of tooth structure
infraction]
Fracture confined to the enamel or might involve dentine

NO PULP EXPOSURE
Uncomplicated crown fracture

Fracture involves enamel and dentine + pulp is exposed

Complicated crown fracture
Crown/ root fractures

Fracture involves enamel + dentine + cementum
No pulp exposure
Uncomplicated crown fracture
Fracture involves enamel + dentine + cementum

+ pulp exposure
Complicated crown fracture
Root fractures
Fracture involves dentine + cementum + pulp
Classified based on :
A. Location of the frcature [ coronal / middle / apical 3 rd ]
complicated fracture [ ALWAYS] B. Prescenece of displacement of the coronal fragement [
coronal / lateral displacement]
Periodontal ligament injury

The traumatic energy that reaches the root is very low
No clinical findings at root level [ the only sign is the tooth is TTP]
Concussion Might be seen with a crown fracture
No displacement or loosening of the tooth
The traumatic energy that reaches the root is low [ but higher than
Subluxation concussion]
Abnormal loosening [ mobility] +No displacement
TTP + Bleeding from gingival crevice
A. Intrusive: tooth displaced into the alveolar bone

Always combined with comminution +/- fracture of alveolar socket
Clinically : the crown is shorter than the adjacent tooth
If all 4 Anteriors are at the same level → means intrusion of both
Luxation
centrals
B. Extrusive :
Partial displacement of the tooth out of the socket in an axial direction
The tooth is usually either protruded or retruded
Clinically : the crown is longer than the adjacent tooth

Alveolar socket is intact

C. Lateral:
Displacement of the tooth in any direction other than axial
Always combined with comminution + fracture of the labial / palatal
alveolar bone - [ checked by palpation]
Partial or total separation of the PDL
Complete displacement of the tooth out of the socket
[If the pt tells you “I couldn’t find the tooth – take a PA it might be a case of
Avulsion complete intrusion or the pt swallowed it → take chest Xray]
Q: why is the traumatic energy that reaches the root is very low in case of concussion?
A. The traumatic energy was low from the start causing only inflammation in the PDL and TTP
B. The traumatic energy was high causing a crown fracture [ which reduces the amount of
energy reaching the root]
Injury to the supporting bone

Crushing + compression of the apical part of the socket
[ not a real fracture]
Comminution of the alveolar socket ALWAYS found with intrusion
Fracture of the facial or lingual socket wall

ALWAYS found with lateral luxation
Fracture of the alveolar socket wall Can be found with avulsion
Fracture above the apical part of the socket [ may or may

not involve the socket ]
Often associated with occlusal interference
Fracture of the alveolar process
Several teeth move together [ Ex: when you push the
central the other central + lateral will move with it ]
Frcature involves the base of the jaw

Fracture of the jaw Often involves the alveolar process +/- socket
treated by OMFS
Injury to the soft tissues

laceration Deep wound or a tear resulting from a sharp object
Bruise [ submucosal hemorrhage ] resulting from a blunt object
Contusion
No break in the mucosa
Superficial BLEEDING wound resulting from rubbing or scraoing of the
abrasion
mucosa
• Trauma is mostly seen in children

• Most commonly seen at 2-5 YO [ when they start walking ] and 8- 12 [ when they start
playing sports ]
• Trauma is more in boys than girls

• Trauma is mainly due to falling or being pushed + mostly affects maxillary centrals
• Most common trauma is uncomplicated crown fractures
• Predisposing factors [ increased overjet + insufficient lip closure ]
Direct trauma: the tooth itself is hit

Indirect trauma : occurs during falls [ the mandible closes forcefully when a person falls and hits the
upper teeth ] → this causes crown fractures in anterior and posterior teeth and crown / root
fractures in posterior teeth + might cause jaw fractures [ condyle and symphysis ]
GENERAL RULES OF TRAUMA :
• High energy→ crown fracture low energy → root fracture/ luxation / alveolar
fracture
• High mass → affects crown low mass → affects roots
• High speed → affects crown low speed → affects supporting structures
• Trauma with cushioned [ blunt] objects → more chance of luxation or alveolar fracture or
root fracture
• Trauma with hard [ sharp ] objects → more chance of crown fractures
• Trauma can have high energy and cause crown fractures → amount of energy reaching
the root is low
Tissue response to trauma

Long term prognosis of the tooth depend greatly on the management in the emergency phase
Pulp response to trauma
Favorable response Unfavorable response
1- Recovery 1- infection
2- Pulp fibrosis [ clinically = increased pain 2- pulp necrosis
threshold , high # on the EPT] 3- internal resorption: caused
3- Pulp obliteration [ clinically = increased pain by injury to the pulp
threshold + tooth might change color to
become more yellow or white ]
Pulp canal obliteration – PCO = occurs 4- external resorption: caused
due to deposition of 3° dentine in by injury to the cementum + a source of
response to trauma infection [ usually pulp
PCO can be: necrosis ]
A. Partial : pulp size is
reduced on xray
B. complete : you can’t
see the shadow of
the canal
• Completely calcified canals with PA radiolucency → RCT

• Some suggest that cases of partial PCO should be treated because they will mostly end
up with complete PCO → necrosis → symptomatic apical periodontitis
• Tooth might intially look like it recovered then have partial PCO → necrosis
Q: give reasons why it is advisable not to interfere and do RCT in cases of partial PCO?

1- Limitations in the radio graph [ there might be a space on the xray but you won’t see
anything after access and if you look for the canal you might end up with a perforation and
extraction ]
2- Not all cases of partial PCO will lead to symptomatic apical periodontitis
It is advisable that you only do RCT for partial PCO if the pt is symptomatic this way if you end up
with a perforation and extraction the pt already had a chief complaint and they would
understand .
After trauma you don’t need to do
Q: what is the management of partial PCO with symptomatic
RCT if there is :
apical periodontitis? Place Ca( OH)2 apically [ the high PH
will neutralize the acidic medium and prevent further • PA radiolucency
odontoclasts differentiation and resorption] • External root resorption
THE ONLY INDICATION FOR RCT AFTER TRAUMA IS • -ve pulp test
EVIDENCE OF INFECTION – PUSS , SINUS TRACT ETC.. • Discoloration of the tooth
Just follow up every month
Peri radicular tissues response to trauma

Favorable response Unfavorable response
1. Recovery 1. Cessation of root development
2. Fibrous healing 2. Disturbance in root development
3. Transient apical breakdown [ TAB] - 3. Bone resorption
injured tissues undergo a spontaneous 4. Gingival recession
process of repair with no permanent 5. External root resorption
damage to the pulp - Misdiagnosis of
this condition may result in unnecessary
endodontic treatment
External root resorption:
• if the source of infection was from the pulp → considered a pulpal response
• If the source of infection was from the PDL → considered a PDL response
EXTERNAL ROOT RESORPTION [ TYPES]
Small superficial resorption in cementum and outer dentine
Considered a repair process – can’t be detected on xray
SURFACE
Occurs after avulsion **
No tx needed
Severely damaged cementum + exposed DT [ loss of tooth surface
externally ]
Bacteria is present inside the canal – resorption can progress
INFLAMMATORY rapidly and needs TX
Occurs after luxation and avulsion **
Most common resorption after failed RCT
Severely damaged cementum → direct contact between bone and
dentine → root becomes part of the bone remodeling process [ root
surface is replaced by bone ]
REPLACEMENT
NO LAMINA DURA + MOTH EATEN APPERANCE OF THE ROOT

Usually occurs many years after trauma – always cervically

Highly vascular [ bleeds on probing]
INVASIVE
Note:
if you have doubts regarding the current RCT and the tooth If there is a PA radiolucency →
will be crowned → you need to do re endo [ even if the pt is
obturate to the full WL [ because
asymptomatic ] because the pt might have balance between
there will be inflammatory resorption
the bacteria present in the canals / PA region and the
even if you can’t see it]
immune defenses but when you place the crown the occlusal
load will change and the balance is affected → resorption
might start
if the RCT is good → no need for re endo
Q: how can you differentiate between external and internal root resorption? Take 2 radiographs while
doing horizontal shifting and then check
Internal root resorption External root resorption

Symmetrical Non symmetrical
Smooth continuous borders Rough non continuous
borders
The borders of the canal will You can still see the borders
be interrupted of the canal
The lesion and the canal will The lesion and the canal
move together when you do move away from each other
shifting when you do shifting
Ankylosis: High to low prognosis :

• can occur before replacement resorption concussion → extrusion / lateral
• can occur after all other types of resorption luxation → intrusion and avulsion
• can occur without resorption
• can lead to replacement resorption no pulp exposure → small exposure
→ large exposure
Trauma to immature teeth :
** ALWAYS WAIT FOR REVASCULARIZATION AND DON’T RUSH TO RCT
No signs of infection Clinical signs of infection [ puss, sinus tract,
swelling , severe pain ] → RCT
• Reposition the tooth to it’s place + stabilize it If enough dentine wall thickness + you can
• Protect the pulp [ pulpotomy or pulp capping] obtain apical seal → conventional RCT
• Monitor by sensibility tests + radiographs
Very thin dentinal walls → re vascularization
You only need to close the apex → apexification


Dental trauma management
General guidelines for trauma management:

1- Psychological support , history , examination and assessment → helps you
establish priorities
2- Control bleeding/ pain ** PRIORITY
3- Protection [ pulp , Root surface (e.g. during repositioning) ]
4- Reposition: Teeth, bone, soft tissues
5- Stabilization: Bone and teeth [splint (rigid or flexible) ] + Soft tissues [sutures]
6- Temporary restorations [ MIGHT BE A PRIORITY IF ESTHETICS IS AFFECTED ]
7- Medications
Systemic: tetanus, antibiotics, analgesics, anti‐inflm.
Local: intra‐canal dressings, chlorhexidine gel, m/w.
8- Follow‐up
1. Psychological support , history , examination and assessment : [establish priorities]

• Smile and be confident and reassure the pt.
If the case is an emergency → control bleeding [ wash the area + apply pressure or do
sutures if needed ] and control pain [ LA or pulp extirpation or medications]
If the case is not an emergency → do full case assessment
History :
Ask when , how and where did the trauma happened?
High energy trauma but the crown did not fracture → consider root fracture
• Chief complaint [ to determine priority]
• Full medical history + tetanus immunization status
• Examination : -ve pulp testing after trauma

A. Mobility [ tested bucco lingually ], percussion, palpation [ to is not an indication for RCT .
check PDL integrity]
if there is mobility in the tooth : Pulp tests are to establish
palapte and if you can feel the margin of the bone → alveolar base line record
bone fracture
if the margin is not felt → root fracture -ve later becomes +ve →
high range of motion = cervical fracture root revascularization
low range of motion = apical fracture
+ve later becomes -ve →
B. pulp sensibility tests [ to establish a baseline and not
diagnosis] pulp necrosis

C. radiographs:
best option is CBCT
take 3 PA + 1 occlusal for affected arch + opposing arch
to check for root frcature you need to do vertical shifting [ you
take 3 radiograph one at 90° to the tooth and one 45° above
an done 45 ° below]
when the xray beam is perpendicular to the tooth → fracture
line appears as tilted line. When the bean is 45° above or
below → fracture appears a s a circle
D. Clinical photographs
For legal purpose + monitor the treatment progress later
2. Protection [ pulp , Root surface (e.g. during repositioning) ]

The aim is to preserve pulp vitality + allow further root development - Specially in immature
teeth that have open apex and thin dentine walls → higher risk of cervical fracture so you
want to preserve pulp vitality to continue root formation + close the apex
Management of complicated / uncomplicated crown fractures

Management of uncomplicated crown facture : dentine protection
Mangement of complicated crown facture : [ pulp exposure]
Mature tooth with thick dentine walls :
If associated with luxation injury or displacement or In case of
failure of pulp capping/ pulpotomy → RCT
Immature tooth - preserve the pulp by :
1- Pulp capping
2- Pulpotomy [ partial or cervical ]
3- Partial pulpectomy
Pulpotomy - removing pulp tissue from the pulp chamber only

Partial [cvek pulpotomy] Cervical
Only the pulp tissue underneath the All of the pulp tissue in the pulp chamber is
expsure is removed [ no access cavity is removed [ you need to do access cavity]
made ]- The pulp chamber still has some
pulp tissue left
Pulpectomy – removing the pulp tissue from the canals
Partial complete
Leave 4-5 mm of pulp tissue apically Completely rmeove all pulp tissue from
canals
[ not an example of pulp protection –
because you rmeove dthe entire pulp]

Highest to lowest success rate in managing exposed pulp [ complicated crown fracture]:
partial pulpotomy → pulp capping → cervical pulpotomy
• Partial pulpotomy has similar success rate to RCT

Procedures for exposed pulp due to trauma [ complicated crown fractures]
Pulp capping Partial Pulpotomy
Closed apex For young pts [ open apex ]

Less than 24 hours and minimal bacterial Small fractures in young pts where the pulp is large
contamination More than 24 hours with bacterial contamination
Procedure: Procedure:
1- Isolation with RD or cotton rolls + suction 1- Isolation
2- Irrigate and achieve hemostasis using a cotton 2- Using an abrasive high speed bur with
pellet of [saline, sodium hypochlorite, CHX] for coolant to remove pulp tissue from the
30 – 40 seconds exposure site
3- Apply capping material 3- Irrigate and achieve hemostasis using a
[ calcium hydroxide , MTA, ledermix or resin modified cotton pellet of [saline, sodium hypochlorite,
calcium silicate (theracal) ] CHX] for 30 – 40 seconds
4- Restorative material 4- Apply capping material
GIC liner then composite [ calcium hydroxide , MTA, ledermix or resin modified
** GIC liner has to be placed to mask the color of calcium silicate (theracal) ]
the capping material before you place composite 5- Restorative material
** if the pt comes with the fractured piece after pulp GIC liner then composite
capping you can place the fragment using flowable
composite and then place a facial composite veneer
Success of pulp capping is not related to :
Age – gender – tooth location – exposure size – Success of partial pulpotomy is not related to :
restoration type Size of the exposure size and time of seeking tx
Q: why is it better to do pulpotomy using a new diamond bur ? because it results in clean surface +
bleeding stops shortly after cutting
NOTE: sometimes after pulp capping or pulpotomy there will be obliteration of the pulp tissue and
calcification of the canal [ due to the presence of the capping material ] . Canal calcification is higher
after partial pulpotomy [ because you are placing more material ]
IMP: In young patients the pulp is large and even small fractures can result in pulp exposure so if you
have small fractured piece → you need to do partial pulpotomy to provide space for the pulp
capping material + GIC + Composite
Q: what decides if you will go for pulp capping or pulpotomy for a complicated crown facture?
1- Age [ open apex → pulpotomy , closed apex → pulp capping]
2- Type of restoration required
3- Bacterial contamination:
A. Time since exposure : less than 24 h → pulp capping , more than 24 h → pulpotomy
After 24 hours the inflammation in the pulp extends 1.5 mm

B. Purgation of the wound: trauma in a dirty environment or by a dirty object and bacterial
contamination is present → do pulpotomy to remove contaminated layers, aseptic
exposure → pulp capping
C. Exposure area : the larger the exposure size the higher the chance of bacterial
contamination
Deep extension : if the trauma was caused by a sharp object that penetrated deep into
the pulp → pulpotomy
Pulp capping / pulpotomy materials:

1- Calcium hydroxide
• Most commonly used agent [ gold standard]
• High PH that causes a superficial layer of necrosis and and underneath layer of calcified
tissue [ the necrotic layer is a requirement for the formation of the calcified layer ]
• Broad spectrum antimicrobial
2- Ledermix cement
• Corticisteroid : Triamcinolone + Antibiotic : Demeclocycline + Calcium hydroxide +
Zinc oxide‐eugenol
• the main content of ledermix = ZOE
• Very strong anti inflammatory agent [ most is released in the first day but full effect is
reached after 3 days ]
• Has the potential to inhibit inflammatory root resorption specially after luxation injuries
When can you place it :
A. Vital pulp tissue remaining inside the canal
B. You did pulp extirpation but you won’t see the pt for a long time
C. the pt is in pain and LA is not effective → place ledermix and then re access after 3-5
days
3- MTA
• Ferrous oxide causes the grey color of MTA / Bismuth oxide causes the discoloration of
MTA when it is applied
• Hydrophilic [ can work in moisture areas]
• Excellent sealing ability [ bacteria tight seal ] + produced a hard tissue bridge faster and
with less defects compared to CaOH2
NOTES IMP:
• If you place non setting Ca OH2 over vital pulp tissue → pt will feel pain
• If you did pulp extirpation and you won’t see the pt for a long time [ multiple weeks ] →
DON’T PUT CaOH2 because it will cause calcifications in the canal
• Ledermix paste = intracanal medication ledermix cement = pulp capping agent
• dentine bridge can be detected : radiographically , clinically [ by microscope ] ,
histologically
• MTA is superior to CaOH2 in pulp capping and pulpotomies but CaOH2 is superior in
apexifications
Protection of the root surface [ only in cases of avulsion] – the aim is to maintain PDL vitality to allow
re implantation + proper healing and prevent root resorption and ankylosis

Management of crown / root fractures

To know if complicated or not → remove fragment + take radiograph or CBCT
Uncomplicated crown root fracture [ without pulp involvement]:
1- Remove the mobile fragment and clean the area
2- Suture gingival lacerations if presents
3- GIC on exposed dentine above gingival level [ if you can’t replace GIC immediately u can do
it maximum after 24 hours ]
4- Expose the margin of the fracture (gingivectomy/crown lengthening/ orthodontic extrusion)
5- Permanent restoration
If no time, or until a definitive treatment plan is made → A temporary stabilization of the
loose segment to adjacent teeth is done
Complicated crown / root fracture [ with pulp involvement] :

A. Non restorable tooth → extraction
B. Restorable tooth :
Complete apex Open apex
• Remove the mobile fragment and clean the • Remove the mobile fragment if does not
area affect restorability OR Stabilize the loose
• Suture gingival lacerations if presents segment to adjacent teeth temporary
• Do RCT then Orthodontic extrusion of apical (Temporary management)
fragment or Crown lengthening • Do Pulp capping or pulpotomy
• Composite/ post & core/ crown then Orthodontic extrusion of apical fragment
or Crown lengthening
• Composite/ post & core/ crown
** for all crown root fracture cases F/U clinically and radiographically after 6-8 week and after 1
year
Management of root fractures

Management of root fractures : [ protection of the pulp tissue and the PDL is not applied in root
fractures]
1- Reposition the tooth with digital finger pressure (if needed)
2- Suture the lacerations (if present)
3- Apply flexible splint for 4 weeks (if mobility)
F/ U after 6-8 weeks, 6 months, 1 and 5 years
Q: Do all cases of root fracture need RCT? No, RCT is indicated if:
A. There are clinical symptoms of irreversible pulpitis
B. During follow up you see evidence of pulp necrosis [ sinus tract , swelling , puss ]
C. You are doing internal splinting

Q: If RCT is done where should it stop? Depends on the case:
• If you are doing RCT because of pulpal necrosis or irreversible pulpitis → you only
do RCT to the coronal fragment [ even if you can reach the apical fragment ] - treat
only to the fracture line and place long term CaOH2 for hard tissue repair.
• If you are doing RCT because you want to do internal splinting → RCT should reach
the the apical fragment.
Internal splinting : indicated if you have multiple root fractures , you stabilize then using fiber
post that connects all parts together .
Q: what is the rationale behind doing RCT only to the coronal fragment in case of root
fracture?
The trauma got reduced greatly at the fracture line which means that the apical part has enough
blood supply + intact nerve fibers and will stay vital [ if failure occurs it will occur at the fracture line
not apical fragment]
Management of concussion / subluxation

Concussion:
• TTP from concussion might not occur immediately , it might be delayed for a few days
• RCT can cause TTP sometimes but it disappears after 3 days
Concussion does not require any treatment – but if severe discomfort you can reduce the
tooth from occlusion a little bit
Follow up: up to 1 year
Subluxation :
• Usually no need for treatment

• A flexible splint for patient comfort up to 2-4 weeks + Soft food for 1 week and OHI
Follow up: up to 1 year
Management of extrusion / lateral luxation

Extrusion Lateral luxation
Both have:
Percussion sensibility: negative
Sensibility test: negative
Radiography: enlargement of apical periodontal space
Excessive mobility + exposure of root High metallic sound + no mobility [
surface because it is contacting bone ]
Management:
1- Rinse the exposed part of the root surface with saline before repositioning
2- Apply a local anesthesia ( specially for lateral luxation)
3- Reposition the tooth with your fingers
4- Flexible splint for 2 weeks (extrusion) and 4 weeks (lateral luxation – because it is mostly
associated with bone fracture)
Follow up: up to 5 years
Initially in lateral luxation / extrusion we don’t do RCT unless there is necrotic pulp.

NOTE: Most cases of extrusion will end up with pulp necrosis so it is advisable to do RCT shortly
after splinting to prevent inflammatory resorption
Management of intrusion
Intrusion
Percussion: has high metallic sound Intrusion is not
No mobility Both intrusion and
Sensibility test: usually negative Radiography: no lateral luxation
periodontal space have high metallic
Tooth looks shorter than adjacent teeth
sound on
considered an emergency [ no need to start definitive treatment percussion and no
right away ] mobility
Immediate treatment for intrusion:

Soft food for 1 week + Brushing with a soft brush and rinsing with chlorhexidine 0.1 %
F/U: 2,4, 6-8 weeks, 6 months, 1 year and yearly for 5 years
Definitive treatment for intrusion: depends on stage of root development and intrusion level
To know how much the root got intruded you can take a CBCT or compare it to the level of the
adjacent tooth
TX options :
1- Spontaneous repositioning
2- Orthodontic repositioning
3- Surgical repositioning
Apex Level of intrusion Management
Open apex Up to 7 mm Spontaneous repositioning
More than 7 mm Orthodontic OR surgical repositioning [ both will
give same results – decision depends on fats the
pt wants the tx ]
Closed apex Up to 3 mm Spontaneous repositioning
3-7 mm Orthodontic OR surgical repositioning
More than 7 mm Only surgical repositioning
** if you see the pt immediately after trauma and both surgery + ortho are indicated → do surgery ,
if you see the pt after the bone and soft tissue healed → do ortho [ to avoid further tissue trauma]
RCT :
• Complete root formation [ closed apex ] → do RCT [ preferably be initiated within 3-4 weeks
post-trauma or 2-3 weeks post surgery ]
After cleaning and shaping you cannot obturate immediately you need to place long sessions
CaOH2 dressing
• Incomplete root formation [ open apex] → only do RCT if there is evidence of pulp necrosis

Q: why do you need to place long sessions of CaOH2 after intrusion injuries? The high PH of CaOH2
will prevent the development of osteoclasts/ dentinoclasts and it will remove the source of infection
and prevent inflammatory resorption
Q: what are the complications of intrusive luxation?
Complications are more in mature teeth
1- Necrosis
2- Replacement resorption
3- Inflammatory resorption
4- Marginal bone loss [ from the trauma itself]
Q: why is inflammatory resorption a complication of intrusion? The trauma causes injury to the
cementum and PDL + if the necrotic pulp is not removed in the correct timing → inflammatory
resorption
Management of avulsion
Best management for avulsion is to reimplant the tooth immediately after avulsion [ you can rinse it
for a few seconds under running water and then reimplant – but washing should not exceed 10
seconds]
First aid that can be done by anyone around the pt [ before they can come to you ]:
1- Calm the pt down
2- Hold the tooth from the crown and wash it briefly under running By preventing the root surface from
water for a maximum of 10 seconds
drying you decrease the chance of
3- Ask the pt to bite on a handkerchief to hold the tooth in position
replacement resorption
4- Seek emergency dental treatment
OR By doing RCT + giving systemic ABX
Hold the tooth from the crown → place in suitable storage you are removing the source of
medium and seek emergency dental treatment infection and reducing the chance of
Best to worst storage mediums [ culture media → milk → saliva
inflammatory resorption
( kept inside the mouth in the cheek) → saline ]
Teeth should never be placed in water [ it will cause lysis of the ALL CASES OF AVULSION REQUIRE
PDL cells] ABX FOR MATURE AND IMMATURE
APEX
Storage media for avulsed teeth:
MEDIUM CHARACTERISTICS
WATER DO NOT USE
Causes rapid cell lysis- does not have the correct osmolarity
Only a quick rinse if nothing else is available
SALINE Tooth can be kept for max 1 hour
Does not contain nutrients for the cells
SALIVA Tooth can be kept for max 2 hour
Contains a lot of bacteria → risk of infection
MILK Tooth can be kept for max 6 hours
Has suitable PH and osmolarity
DO NOT USE YOUGURT OR SOUR MILK → PH IS TOO LOW AND NOT SUITABLE

TISSUE CULTURE BEST TO USE – rarely available [ because the solution has to be kept at 4°
MEDIUM Tooth can be kept for 4 days
HANK’S Can be kept at room temp
BALANCED SALT
SOLUTION [
HBBS]
Save a tooth : half filled with HBBS and contains wither a basket or
chambers to limit the tooth mobility and reduce the chance of damage to
the cells
In clinic: 2 scenarios
Tooth has been re planted
1- Clean the area
2- Verify normal position of the replanted tooth
3- Suture gingival lacerations if present
4- Apply a flexible splint for up to 2 weeks
5- Administer systemic antibiotics
• Tetracycline (Doxycycline 2mg/ kg of body weight 2x per day for 7 days)
OR
• Phenoxymethyl Penicillin or amoxycillin
Refer to physician for a tetanus booster
CAUTION : IF THE PT IS BELOW 8 DO NOT GIVE TETRACYCLINE AND GIVE PENICILLIN INSTEAD
PT instructions:
Avoid participation in contact sports
Soft food for up to 2 weeks
Brush teeth with a soft toothbrush after each meal
Use a chlorhexidine (0.1 %) mouth rinse twice a day for 1 week
F/U = Clinical and radiographic control after 2, 4 weeks, 3, 6 months, 1 year and then yearly thereafter
Tooth is still outside the socket

A. Extraoral dry time is less than 60 mins [ PDL cells are still vaible]
Soak the tooth in saline to remove contamination and dead cells
IF INCOMPLETE APEX : Topical application of antibiotics (minocycline or doxycycline 1 mg per 20 ml saline for 5
minutes soak)
IF COMPLETE APEX: RCT is indicated, can be initiated in 7-10 days
Then
local anesthesia, examine the socket [ clean and irrigate the socket + remove blood clot]
Replant the tooth gently + Apply a flexible splint for up to 2 weeks
Administer systemic antibiotics
• Tetracycline (Doxycycline 2x per day for 7 days)
OR
• Phenoxymethyl Penicillin (Pen V) or amoxycillin
B. Extra oral dry time more than 60 mins [ no PDL cells ]

Remove attached non-viable soft tissue carefully

Root canal treatment can be performed (closed apex)
Treat the root surface with 2 % sodium fluoride solution for 20 min [ to decrease the chance of
replacement resorption]
local anesthesia, examine the socket [ clean and irrigate the socket + remove blood clot]
Administer systemic antibiotics
• Tetracycline (Doxycycline 2x per day for 7 days)
OR
• Phenoxymethyl Penicillin (Pen V) or amoxycillin
PT instructions:
F/U = Clinical and radiographic control after 2, 4 weeks, 3, 6 months, 1 year and then yearly thereafter
RCT indications in avulsion :

1- Tooth replanted before arrival to clinic and tooth has
closed apex → do RCT after 7- 10 days RCT in trauma is indicated in :
2- Tooth [ with closed apex] was extraorally less than
6o mins → do RCT after 7-10 days Complicated crown fractures or Crown /
3- Tooth with [ open or closed apex ] was extraorally for root fractures
more than 60 mins → you can do RCT immediately
or after 7- 10 days And 2-3 week after intrusion repositioning
ABX are only indicated in cases of avulsion
repositioning and stabilizing always come together

Repositioning tooth or bone: Anesthesia - Use gentle finger forces - Always check occlusion - Take x-
ray – apply suitable splint
Stabilizing:
A. Soft tissues : by sutures [ for optimum healing + maintain tissue position and prevent
gingival recession]
Q: what happens if you don’t suture? Poor healing + Gingival recession and bone loss
B. Bone and teeth : by splints

Splinting
Flexible [ functional, semi rigid, non rigid splint] Rigid splint
Most commonly used splints Two adjacent teeth from each side are included
Extends to include one tooth on each side [ if you increase the # of teeth included on each side
Reduces the risk of ankylosis of the splint you will increase the rigidity of the splint
Allows functional healing of the PDL even if you use the same material ]
EX: composite + ortho wire [ composite splint] EX: titanium ring splint
Titanium trauma splint Bracket splint , schuchardt splint
Used in: Used in:
Splinting teeth with alveolar process fractures
dislocation injuries or root or root fractures in the
fractures in the middle / cervical part
apical 3rd
Splint requirements:
1- can be created quickly outside the lab using conventional dental materials + in
expensive
2- easy to apply - easy to remove without damaging dental hard tissue
3- should not traumatize teeth or surrounding tissues
4- should not interfere with occlusion, dental hygiene, or endodontic treatment.
5- should help restore the original tooth position
6- ensure adequate fixation over the entire immobilization period
7- should achieve rigidity or flexibility
• intrusion / extrusion / lateral luxation → semi rigid splint for 2 weeks
• alveolar bone fracture → rigid splint for 4 weeks
• cervical root fracture → 4 months
Temporary restorations in trauma cases:
1- fragment restoration:
if the broken fragment was kept in a dry environment [ gauze / tissue ] it
has less chance for success + it will have a different color that the rest of
the tooth
to prevent the color change:
A. keep the fragment in suitable solution
B. do a labial composite veneer over the fragment
2- fiber post and crown : if the entire crown is lost → you do partial pulpectomy +
place a temp fiber post inside the canal and etch and coronal part of the post
and build it up with composite then cement the post using ZOE
3- If you don’t have enough time: cover the tooth with Vaseline and then inject FUJI 9 GIC
slightly inside the canal and let it overflow and remove it and seat it several times then
cement it

Medications in trauma cases :

Q: when should you give ABX in trauma ? medically compromised pt and all cases of avulsion
In avulsion:
SYSTEMIC : LOCAL :
• Tetanus toxoid ➔ Check status (10 years) – • Intracanal dressing of ledermix paste
specially if the wound is contaminated with dirt • CHX gel apply with cotton bud or
• Antibiotics : Penicillin / amoxycillin OR finger 2-3 times daily for 2-3 weeks
Tetracyclines [ best] • CHX mouthwash : after each meal and
• NSAID’s : Ibuprofen - Synergism with until 2 days after suture removal
tetracyclines
• Use NSAID’s for analgesic + anti-inflammatory
actions
C
Follow up : In every follow up you :
1- Examine soft tissues
2- Examine teeth [ percussion / palpation / mobility/ color changes ]
3- Pulp testing [ cold test + EPT]
4- PA radiographs + clinical photographs
• Suture removal after 5- 6 days
• Flexible splint removed after 2 weeks, rigid splint after 4 week
NOTE: if RCT is indicated after trauma it can still be delayed for 10- 14 days

Management of root resorption

1- Internal resorption : asymptomatic and is a chance radiographic appearance only painful if
there is perforation
• Pink tooth in case of cervical resorption
• RCT IS INDICATED OTHERWISE TOOTH NEEDS EXO
Without perforation With perforation

RCT [ irrigation with US activation + place Depending on the perforation location and
CaOH2 for a while then obturate using warm GP extent:
technique] A. If you can seal the perforation from
inside the canal → CaOH2 or MTA
B. Surgical repair
C. Extraction
External resorptions:
1- Surface resorption:
• Rarely seen on radio graph – No tx needed [ it is part of the normal healing response]
2- Inflammatory resorption : [ trauma to PDL / cementum + infection]
• The only type that can be controlled
• Seen in luxation, intrusion or avulsion
• May arrest with RCT
• Prevented by the systemic ABX and pulp removal [ removing the source of infection]
3- Replacement resorption :
• Associated with reimplantation
• Transient → no tx just follow up
• Progressive [ associated with PDL removal ] → extraction
If replacement resorption is only apically → push CaOH2 out of the apex [ it’s high pH will
arrest the resorption]

invasive cervical resorption - ICR

Causes of ICR:
The actual cause is unknown but there are predisposing factors
1- Ortho treatment and orthognathic surgery ** [ most common cause]
2- Trauma / bruxism
3- GTR + tetracycline conditioning of the root
4- Reimplantation of avulsed teeth **
5- Intracoronal Bleaching [ specially if it was done by hydrogen peroxide and heat activation]
6- Restorations near or at the cervical margin
** mostly it is trauma + other factors that cause ICR
Clinical Features:
1- Located cervically
2- Resorbed cavity is replaced by high vascular tissue → severe
bleeding on probing in that area
3- No pain [ because the pulp remains protected by an intact layer of Pink coronal discoloration is
dentin and predentine until late in the process]
found in both internal
4- In late stages , ectopic calcifications deposited directly onto the
resorption and ICR
resorbed dentine surface
5- may be evident as a pink coronal discoloration
In the late stages of invasive cervical resorption → pain + ectopic calcifications
Radiographical features:
• Varies from a well delineated to an irregularly “moth-eaten" radiolucency

which can be confused as root caries
• A characteristic radio-opaque white line between the lesion and the pulp
[represents the predentine and dentine]
• To differnetiate between root caries and ICR you need to depend on the
clinical features of ICR [ bleeding on probing ang pink disocloration]
In case there is a gap between cementum and enamel → most susceptible to ICR
Resorption occurs in 2 phases:
1- ICR originates in the cervical area below the epithelial attachment
→ proceeds from a small cervical opening to involve a large part of
dentin between the cementum and the pulp
2- It progresses and reaches the predentin, then spreads laterally in an
apical and coronal direction enveloping the root canal (Predentin is
more resistant to resorption)

CLASSIFICATION OF INVASIVE CERVICAL RESORPTION

BASED ON SPREAD INTO DENTINE
A small lesion with shallow penetration into dentine
CLASS I
lesion that has penetrated close to the coronal pulp chamber but shows little or
no extension into the radicular dentin
CLASS II
Lesion involving the coronal dentine + extending at least to the coronal third of
the root
CLASS III
Lesions extends beyond the coronal third of the root canal and may involve
almost the entire root
CLASS IV
FRANK’S CLASSIFICATION [ RELATION WITH THE CRESTAL BONE] – USED TO DETERMINE TX

not accompanied by periodontal breakdown
INTRA
OSSEOUS
At the level of the alveolar bone

CRESTAL
coronal to the level of the alveolar bone

SUPRA-
OSSEOUS
Treatment: stop the resorptive process and restore the lost tooth structure – if the cervical
resorption is not cleaned properly and some tissue is left → lesion will continue to cause resorption
Management of ICR
An external approach Crestal ICR Internal approach
FOR SUPRA OSSEOUS ICR and FOR INTRAOSSEOUS
CRESTAL ICR ICR
flap reflection → curettage and Traditionally, tooth was treated by RCT RCT followed by internal
restoration with amalgam or followed by repair of the resorptive area by repair
composite resin or GIC or MTA internal approach or external approach
** in case of pulp exposure during Recently, external approach is preferable = if
external approach → RCT there is exposure / symptoms→ RCT
DISADV= gingival recession [ MTA is suggested in this case
prevented by GTR membranes (
Gortex)]
** MTA can be used for both internal and external approaches

In treating ICR we always try to avoid doing an RCT [ maintain pulp vitality] unless there is an
indication.
RCT is NOT needed in class I and class II and if the pulp is vital and testing within normal limits
RCT indications in ICR cases:
1- Pulp exposure
2- Non vital tooth [ necrotic pulp]
3- Class III or IV resorption [ because any attempt to debride the area will result in pulp
exposure or irreversible pulpitis ]
4- Resorption extending to more than one surface
5- Tooth is symptomatic
Clinical management of ICR cases [ class I and class II ] :
To know if the resorption has spread to other areas → take CBCT before you access
1- Apply glycerol to protect soft tissues
2- curette the soft tissue from the defect using excavator [ avoid using hand piece because it
can easily remove the thin pre dentine layer causing pulp exposure ]
3- Topical application of 90% aquous solution of TCA “Trichloro acetic acid” in a cotton pellet (>
1 min) – the cotton pellet with TCA should be pushed against gauze to remove excess
material
TCA will ensure that the dentinoclasts are removed from the defect BUT it causes
coagulation necrosis of soft tissue - results in a surface that does not bond well
CAUTION: avoid touching the gingiva with TCA → it can cause chemical burns
4- Restore the defect with GIC
GIC is :
well tolerated by the periodontium when placed subgingivally
provides immediate seal (unlike MTA) – MTA has long setting time and by the time it sets
some of it would get out of the Cavity
esthetically acceptable + can easily be veneered with composite when necessary
if you access and then see that the lesion has spread to other surfaces → do RCT and combine
internal and external approach together
class IV → extraction The most important thing in ICR
Q: why is the prognosis od ICR is uncertain ? because you cannot treatment is removing all of the
determine if you removed all the inflammatory tissues from the inflammatory tissues
lesion

Summary of trauma management

Trauma Management Follow up
Concussion No treatment needed but if the pt has discomfort you can reduce the Up to one year
tooth from occlusion a little bit
Subluxation No treatment is usually needed for pt comfort place a flexible split for
2- 4 weeks + instruct the pt to have soft diet for 1 week
Extrusive / lateral 1- Rinse the exposed part of the root surface with saline before up to 5 years
Luxation repositioning
2- Apply a local anesthesia ( specially for lateral luxation)
3- Reposition the tooth with your fingers
4- Flexible splint for 2 weeks (extrusion) and 4 weeks (lateral
luxation – because it is mostly associated with bone fracture)
Initially in lateral luxation / extrusion we don’t do RCT unless there is
necrotic pulp.
Most cases of extrusive luxation will end up with necrosis → do RCT
shortly after splinting
Intrusion Immediate tx : soft diet for one week + Brushing with a soft brush 2,4, 6-8 weeks, 6
and rinsing with chlorhexidine 0.1 % months, 1 year and
Definitive tx : Depends on the level of intrusion and the apex. yearly for 5 years
Open apex [ less than 7 mm intrusion ] → spontaneous repositioning
Open apex [more than 7 mm intrusion] → ortho or surgical
repositioning
Closed apex [ up to 3 mm intrusion ] → spontaneous repositioning
Closed apex [ 3-7 mm intrusion] → ortho or surgical
Closed apex [ more than 7 mm intrusion ] → surgical repositioning
RCT is indicated in all closed apex , and only indicated in open apex if
there is evidence of necrosis [ place long session of CaOH2]
Crown fractures
Trauma Management Follow up
Crown infraction TX needed to minimise chances of bacterial ingress to the pulp that is No follow up needed -
possibly damaged or inflamed from trauma + to prevent the discoloration Unless they are
of the infraction lines. associated with other
Etching and sealing with resin to prevent discoloration of the infraction types of trauma
lines - Apply as soon as possible after trauma to minimise bacterial
penetration
Uncomplicated Dentine protection with liners then composite restoration Clinical and
crown fracture radiographic control
Complicated Pulp capping / pulpotomy at
crown fracture RCT - in older patients with completely formed teeth especially if 6-8 weeks
associated with luxation injury or displacement or In case of failure of pulp 1 year
capping/ pulpotomy
Uncomplicated Remove segment →clean area + suture lacerations then place GIC on
crown root exposed dentine and exposure the fracture margin with
fracture [gingivectomy/crown lengthening/ orthodontic extrusion] → final
restoration
Complicated Unrestorable tooth → extraction
crown root Restorable tooth:
fracture Mature apex : Remove segment → clean area + suture lacerations then do
RCT followed by crown lengthening or ortho extrusion and final restoration [
composite post / core / crown]

Immature apex: Remove segment → clean area + suture lacerations then

do pulp capping / pulpotomy followed by crown lengthening or ortho
extrusion and final restoration [ composite post / core / crown]
Root fracture Reposition the tooth with digital finger pressure (if needed) after 6-8 weeks, 6
Suture the lacerations (if present) months, 1 and 5
Apply flexible splint for 4 weeks (if mobility) years
Avulsion Tooth has been replanted before arriving to clinic:
1- Clean the area + verify normal position of the replanted tooth
2- Suture gingival lacerations if present
3- Apply a flexible splint for up to 2 weeks
4- Administer systemic antibiotics
Extraoral dry time is less than 60 mins [ PDL cells are still vaible]:
1. Soak the tooth in saline to remove contamination and dead
cells
IF INCOMPLETE APEX : Topical application of antibiotics
(minocycline or doxycycline 1 mg per 20 ml saline for 5 minutes
soak)
IF COMPLETE APEX: RCT is indicated, can be initiated in 7-10 days
2. local anesthesia, examine the socket [ clean and irrigate the

socket + remove blood clot]
3. Replant the tooth gently + Apply a flexible splint for up to 2
weeks
Extra oral dry time more than 60 mins [ no PDL cells ]
Remove attached non-viable soft tissue carefully
Root canal treatment can be performed (closed apex)
Treat the root surface with 2 % sodium fluoride solution for 20 min [
to decrease the chance of replacement resorption]
local anesthesia, examine the socket [ clean and irrigate the socket
+ remove blood clot]
For all cases u prescribe ABX:

• Tetracycline (Doxycycline 2mg/ kg of body weight 2x per day
for 7 days)
OR
• Phenoxymethyl Penicillin or amoxycillin
CAUTION : IF THE PT IS BELOW 8 DO NOT GIVE TETRACYCLINE AND
GIVE PENICILLIN INSTEAD
PT instructions:

Endodontic surgery
Endodontic Surgery should be the choice only when non-surgical treatment has failed or the problem
cannot be treated non-surgically
ENDODONTIC SURGICAL TECHNIQUES :

A. SURGICAL FISTULATION
1. Incision and drainage
2. Cortical trephination
B. PERIRADICULAR SURGERY
1. Periradicular curettage
2. Root-end resection (apicoectomy)
3. Root-end preparation (retroprep)and root end filling (retrofilling)
C. CORRECTIVE SURGERY
1. Perforation repair
a. Resorptive and carious
b. Mechanical
2. Periodontal management
a. Root amputation
b. Hemisection
c. Regenerative techniques
d. Exploration to confirm suspected vertical root fracture
3. Intentional replantation (Extraction-Replantation)
4. Surgical repositioning of luxated teeth
5. Surgical uncovering and orthodontic extrusion of endodontically treated teeth
6. Decompression of large periradicular lesions

Indications for Periapical Surgery :
• Biopsy of the periapical lesion is required

• Foreign body reaction with extruded material
• Perforation repair (that can not be done conservatively)
• If non-surgical treatment is not feasible - such as:
o Very long or wide post; Post not in line with canal
o Canal blocked by broken file, calcifications, etc
o Tooth is not likely to be suitable for further restoration
• Patient factors (Medical / dental condition, time, costs, recent crown, etc.)
CONTRAINDICATIONS FOR SURGICAL ENDODONTICS

A. PATIENT'S MEDICAL STATUS
1. Uncontrolled hypertension
2. Recent myocardial infarction
3. Uncontrolled diabetes
4. Dialysis patients
5. Uncontrolled bleeding disorders
6. Immuno-compromised patients
B. Patient’s mental / psychological health:
1. Patient does not desire surgery
2. Patient unable to handle stress of long
complicated procedure
3. Patient extremely apprehensive
C. Non restorable tooth
D. Poor periodontal prognosis
E. Inadequate access to surgical area
1. Thick buccal cortical
plate/external oblique ridge
2. Limited opening
3. Shallow palatal vault
4. Shallow vestibule

Endodontic Surgery steps:

1. Local Anaesthesia
2. Consultation, Diagnosis, Treatment Plan
3. Periosteal Flap
4. Curettage
5. Apicoectomy
6. Retrograde Endodontic Treatment (Apical Bevel, Canal Preparation, Root Filling)
7. Wound Closure - sutures
8. Post-operative Instructions
9. Follow-up & Review
Flap designs
▪ Semi-Lunar
▪ Gingival crest (Intrasulcular)
1- a)Triangular b)Trapezoidal
2- Gingival
▪ Luebke-Oschenbein

Flap Designs Advantages Disadvantages

In the mucobuccal fold and attached gingiva ▪ Poor access
▪ Incision often over the lesion
▪ Difficult moisture control
(haemorrhage)
Semi-Lunar ▪ Difficult to reposition
▪ Uncomfortable during healing
▪ Leaves scars
▪ Horizontal incision not ▪ Difficult flap elevation

crossing bone defect. ▪ Irreversible pocket formation if
▪ Greater access for lateral used in presence of dehiscence
root repair ▪ Long vertical and horizontal
▪ Useful in short roots and incisions required
coronal third defects ▪ Changes in the level of the
Gingival crest ▪ Easy reposition marginal gingiva
(Intrasulcular) ▪ Maximal blood supply ▪ Difficult suturing
▪ Difficult to maintain oral hygiene
during healing period
✓ “First choice” flap for endodontic
Triangular surgery
◼ Good access
◼ Good vision
◼ Good moisture control
◼ Heals without scars
◼ Easy to reposition
Begin as a triangular flap and ✓ “Second choice” for endodontic

Trapezoidal then do 2nd vertical incision if surgery
extra access required ◼ Good access & vision
◼ Good moisture control
◼ Heals without scars
◼ Easy to reposition
Gingival Extended horizontal incision ▪ No access to apex

No vertical incision ▪ May be useful for coronal
third perforations
▪ Used for palatal flaps But difficult !
Scalloped horizontal incision in attached ▪ Simple ▪ An unaesthetic scar may form

gingiva ▪ Good access ▪ Muscular attachments &
▪ No gingival recession, frenums may need modification
◦ 3 - 5 mm short of the gingival margin
because the marginal of the horizontal incision
◦ Follows contours of the gingival margin gingiva is not disturbed. ▪ Misjudging the size of lesion
Vertical incisions (Use for anterior teeth may result in the incision
◦ 1 or 2 mm short of entering the with crowns) crossing the osseous defect
mucobuccal ▪ Easily repositioned flap
Fold (Depends on how much access is ▪ The patient is able to
Luebke- required) maintain good oral
Oschenbein hygiene during the
healing period

General Principles for Periosteal Flaps
1- The incision for a full mucoperiosteal flap

(mucosa, connective tissue, periosteum)
must be made with a firm continuous stroke.
2- An incision should not cross an existing
underlying bony defect.
3- The vertical incision (s) should be made in the concavities between bone
eminences.
4- The vertical incision should not extend into the mucobuccal fold
5- The termination of the vertical incision at the
gingival crest must be at the mesial or distal
line angle of the tooth.
6- The base of the flap must be at least equal to
the width of its free end.
Apical Bevel
Done by:
1-Round bur or 2-noncutting-tip fissure bur
Amount of root removed depend on: 1-Degree needed to examine root exits,
zips, perforation
2-Wide surface to prepare Class I cavity
Curettage Techniques :
To remove all pathologic tissue, foreign bodies, and
root and bone particles from the periradicular area.

Retrograde filling materials

Amalgam - Cavit - IRM - Super-EBA - Composite resins - Gutta percha - Glass ionomers - MTA
Retrograde Filling Disadvantages & Problems

Materials
Amalgam  Corrosion  Difficult to condense
 Galvanism (with posts)  Condensation scatter
 Tattoo on mucosa  Cavity large
 Expansion  Undercuts needed
 Dimensional changes  Poor adaptation to walls
 Marginal breakdown  No anti-bacterial action
 Excess not absorbable  Difficult to remove for
 Mercury release re-treatment
 Poor tissue compatibility

◦ Due to continuous release of eugenol
◦ Fibrosis of adjacent tissue
IRM + Super-EBA  Soluble
 Large cavity required
 Difficult to handle material
◦ Esp. Super-EBA
 Low tissue toxicity  Moisture control
◦ Bone apposition ◦ Haemorrhage
 Good sealing ability  Relatively large cavity required
 Chemical bond to dentine
Glass Ionomer  Radiopaque
 Easy to mix & place
 Colour contrast to tooth
 Short setting time
 Low tissue toxicity  Easy to mix & place

 Good sealing ability  Good physical properties
 Radiopaque  Satisfies requirements of
Gutta Percha +
 Colour contrast to tooth root filling materials
Sealer
 Conservative cavity only  Proven and acceptable
 Anti-bacterial (sealer) material for RCF’s for
over 120 years
 Superior seal compared with  Relatively large cavity required

Super EBA  No resistance to dense
 Low toxicity compaction
MTA (Mineral trioxide
 Healing of the p.a. tissues with  Washing out the material during
aggregate)
cementum forming over the flush the bony crypt
material  Setting time 2-4 hours
 Need moisture to set

Endodontic Surgery Kit :

 Explorer + mirror + Twizer
 Scalpel
 Periosteal elevator
 Curette
 Tissue Retractors
 Tissue & suture scissors
 Needle holder
 Tissue forceps
No. 15 - for periosteal flaps No. 11 - for incision and drainage (Stabbing action)
Hemorrhage Control
1-Adrenaline → with pressure
2-Bone wax (Mechanical)
3-Ferric sulfate
4-Microcrysatalline collagen substances
After placement of root end filling, an interim radiograph should be exposed to ensure that:
1-Root tip has been totally removed.
2-No excess material is present in the ossous crypt.
3-Placement of root end filling is adequate.
Suturing( with absorbable or non absorbable suture)

After suturing: The flap should be compressed with digital pressure and
a moist gauze for 5 – 10 mins. To decrease the size of coagulum and
enhances healing.
Post-Operative Instructions
1. Ice pack(10 mins. on & 10 mins. off)
2. Rest for a day
3. Analgasics & NSAIDs drugs (ibuprofen)
4. Antibiotics (only) in case of signs and symptoms of systemic infection, or patient medical
status
5. Rinsing of surgical site with warm salt water 3-4 times a day, beginning the day after surgery.

References
▪ Hargreaves, Kenneth M., and Louis H. Berman. Cohen's pathways of the pulp expert
consult. Elsevier Health Sciences,2015.
▪ Garg, Nisha, and Amit Garg. Textbook of endodontics. Boydell & Brewer Ltd, 2010.
▪ Koch, Ken, and Dennis Brave. "Real World Endo: Design features of rotary files and how
they affect clinical performance." Oral Health 92,no. 2 (2002): 39-49.
▪ Sanghvi, Zarna, and Kunjal Mistry. "Design features of rotary instruments in
endodontics." The Journal of Ahmedabad Dental College and Hospital 2,no. 1 (2011): 6-
11.
▪ Peters, Ove A., and Frank Paque. "Current developments in rotary root canal instrument
technology and clinical use: a review." Quintessence international (Berlin, Germany:
1985) 41, no. 6 (2010): 479-488.
▪ Carrotte, P. V., and P. J. Waterhouse. "A clinical guide to endodontics–update part 2."
British dental journal 206, no. 3 (2009): 133-139
▪ Tabassum, S. and Khan, F.R., 2016. Failure of endodontic treatment: The usual suspects.
European journal of dentistry, 10(1), p.144.
▪ Cheung, W., 2005. A review of the management of endodontically treated teeth: post,
core and the final restoration. The Journal of the American Dental Association, 136(5),
pp.611-619.
▪ Peroz, Ingrid, Felix Blankenstein, Klaus-Peter Lange, and Michael Naumann. "Restoring
endodontically treated teeth with posts and cores—a review."Quintessence Int 36, no. 9
(2005): 737-46.
▪ Cvek (1978). A clinical report on partial pulpotomy and capping with calcium hydroxide
in permanent incisors with complicated crown fracture. J Endod 1978; 4(8): 232-7.
▪ Rankow, H.J. and Krasner, P.R., 1996. Endodontic applications of guided tissue
regeneration in endodontic surgery. Journal of endodontics, 22(1), pp.34-43.
▪ Smidt, A., Nuni, E. and Keinan, D., 2007. Invasive cervical root resorption: treatment
rationale with an interdisciplinary approach. Journal of endodontics, 33(11), pp.1383-
1387.

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Crash Course in Endodontics

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CRASH COURSE IN

DONE BY : SIMA HABRAWI

Done By : Sima Habrawi Dentiscope 2020

Rotary endodontics .............................................................................................................. 51

Done By : Sima Habrawi Dentiscope 2020

Done By : Sima Habrawi Dentiscope 2020

• A – FIBERS = largest diameter - fast conducting → localized sharp pain

Done By : Sima Habrawi Dentiscope 2020

Innervation of pulp is both simple and complex

 Simple – only free nerve endings and so lacks proprioception

Done By : Sima Habrawi Dentiscope 2020

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

• Colonization = establishment of microorganisms in a host

Done By : Sima Habrawi Dentiscope 2020

Diagnosis and treatment planning

Causes of false positive of EPT Causes of false negative of EPT

Done By : Sima Habrawi Dentiscope 2020

Other tests that should be done during endo diagnosis:

• Anterior tooth → transillumination

Done By : Sima Habrawi Dentiscope 2020

PULP SYMPTOMS /TESTS TREATMENT

Done By : Sima Habrawi Dentiscope 2020

Peri apical diagnosis

1- Peri apical granuloma:

Done By : Sima Habrawi Dentiscope 2020

1- Asymptomatic [ discovered on routine radiographs] ** extension of

Done By : Sima Habrawi Dentiscope 2020

A type of chronic apical periodontitis to a

• Most diagnostic symptom of symptomatic apical periodontitis = pain on chewing / TTP

Done By : Sima Habrawi Dentiscope 2020

Decision tree for Pulpal

Decision tree for

Cavity sealers: [ cavity varnish / bonding agents ]

Cavity Liners : few microns → Cavity bases : few mm thick →

Pulp capping: procedures done when

Requirements of pulp capping :

Done By : Sima Habrawi Dentiscope 2020

Indirect pulp capping Direct pulp capping

Pulpectomy : RCT [ coronal and radicular pulp is removed]

Done By : Sima Habrawi Dentiscope 2020

Done By : Sima Habrawi Dentiscope 2020

Size 1 Narrow arches and anterior teeth

** PA lesions are always smaller on radiographs

Tube shift techniques

Done By : Sima Habrawi Dentiscope 2020

Hand instruments: [ numbered from 10- 100]

Done By : Sima Habrawi Dentiscope 2020

Instruments for cleaning and shaping the canals

Lentilospiral: latch type attachment – used to carry Gates Glidden :

Nickel titanium instruments: NiTi

spreaders: used to pack GP [ sizes from 15-45]

pluggers : diameter wider then spreaders – blunt end

Done By : Sima Habrawi Dentiscope 2020

Done By : Sima Habrawi Dentiscope 2020

Extra canals are mostly found in :

• Upper molars mostly have MB2 Dilaceration: extreme

Done By : Sima Habrawi Dentiscope 2020

ACCESS CAVITY DESIGN:

To find MB2 canal in upper molars:

Mostly located between the MB and palatal