Before the actual operative aspects of root canal thera-

py are begun, a number of preparatory procedures

must rst be completed:
1. Radiography is needed, rst as an aid to diagnosis,
then periodically during treatment. Endoscopy,
orascopy, and the surgical microscope are supple-
mental aids to visual enhancement.
2. Specialized endodontic instruments and equipment
must be arranged for ready use.
3. Local anesthesia of the involved tooth or area may be
necessary. Special problems of anesthesia also may
arise, particularly with mandibular molars and in
the case of an inamed pulp.
4. Rubber dam placement sometimes requires special
handling in endodontics.
ENDODONTIC RADIOGRAPHY*
No single scientic development has contributed as
greatly to improved dental health as the discovery of the
amazing properties of cathode rays by Professor
Wilhelm Konrad Roentgen in November 1895. The sig-
nicant possibilities of their application to dentistry
were seized upon 14 days after Roentgens announce-
ment, when Dr. Otto Walkoff took the rst dental radi-
ograph in his own mouth.
1
In the United States, within
5 months, Dr. William James described Roentgens
apparatus and displayed several radiographs. Three
months later, Dr. C. Edmund Kells gave the rst clinic in
this country on the use of the x-ray for dental purposes.
Three years later (1899), Kells was using the x-ray to
determine tooth length during root canal therapy.
I was attempting to ll the root canal of an upper cen-
tral incisor, Kells later said. It occurred to me to place a
lead wire in this root canal and then take a radiogram to
see whether it extended to the end of the root or not. The
lead wire was shown very plainly in the root canal.
One year later (1900), Dr. Weston A. Price called
attention to incomplete root canal llings as evidenced
in radiographs. By 1901, Price was suggesting that
radiographs be used to check the adequacy of root
canal llings.
2
Price is also credited with developing the
bisecting angle technique, whereas Kells described what
today is called the paralleling technique, made popular
some 40 years later by Dr. Gordon Fitzgerald.
Although these early attempts were rarely of diag-
nostic quality, they were the beginning of a new era for
all of dentistry. For the rst time, dentists could see the
accumulation of past dental treatment therapy done
without knowledge of what lay beneath the gingiva.
Needless to say, the calamitous ndings must have dis-
heartened the conscientious practitioner. Yet even
today, with all of the modern engineering renements,
the sleekness of operation, and the reduction of haz-
ards, a discouraging segment of our profession contin-
ues to deprive the public by failing to use radiography
to its full potential.
The total application of roentgen rays and the disci-
plined interpretation of the product are beyond the
scope of this textbook. Only the utilization of radiogra-
phy in endodontics will be discussed here. Suffice it to
say that radiography is absolutely essential for root
canal therapy.
Application of Radiography to Endodontics
The roentgen ray is used in endodontic therapy to (1)
aid in the diagnosis of hard tissue alterations of the
Chapter 9
PREPARATION FOR
ENDODONTIC TREATMENT
John I. Ingle, Richard E. Walton, Stanley F. Malamed,
Jeffrey M. Coil, John A. Khademi, Frederick H. Kahn,
Barnet B. Shulman, James K. Bahcall, and Joseph T. Barss
*Abstracted in part from Walton RE.
27
teeth and periradicular structures; (2) determine the
number, location, shape, size, and direction of roots
and root canals; (3) estimate and conrm the length of
root canals before instrumentation; (4) localize
hard-to-nd, or disclose unsuspected, pulp canals by
examining the position of an instrument within the
root (Figure 9-1); (5) aid in locating a pulp that is
markedly calcied and/or receded (Figure 9-2); (6)
determine the relative position of structures in the
faciallingual dimension; (7) conrm the position and
adaptation of the primary lling point; (8) aid in the
evaluation of the nal root canal lling; (9) aid in the
examination of lips, cheeks, and tongue for fractured
tooth fragments and other foreign bodies (except plas-
tic and wood) following traumatic injuries; (10) aid in
localizing a hard-to-nd apex during periradicular sur-
gery; (11) conrm, following periradicular surgery and
before suturing, that all tooth fragments and excess ll-
ing material have been removed from the apical region
and the surgical ap; and (12) evaluate, in follow-up
lms, the outcome of endodontic treatment.
Limitations of Radiographs
Radiographs have their limitations! They are sugges-
tive only and should not be considered the singular
nal evidence in judging any clinical problem. There
must be correlation with other subjective and objective
ndings. The greatest fault with the radiograph relates
to its physical state; it is a record of a shadow, and as
such only two dimensions are shown on a single lm.
As with any shadow, these dimensions are easily dis-
torted through improper technique, anatomic limita-
tions, or processing. In addition, the buccal-to-lingual
358 Endodontics
dimension is absent on a single lm and is frequently
forgotten, although techniques are available to dene
the third dimension. These techniques are described
later in detail.
Radiographs are not infallible. Various states of pul-
pal pathosis are indistinguishable in the x-ray shadow.
Neither healthy nor necrotic pulps cast an unusual
image. Correspondingly, the sterile or infected status of
hard or soft tissue is not detectable other than by infer-
ence. Only bacteriologic evidence can determine this.
Furthermore, periradicular soft tissue lesions cannot be
accurately diagnosed by radiographs; they require his-
tologic verication. Chronic inammatory tissue can-
not, for example, be differentiated from healed, brous,
scar tissue, nor can a differential diagnosis of peri-
radicular radiolucencies usually be made on the basis
of size, shape, and density of the adjacent bone.
37
A
common misconception is that an inammatory lesion
is present only when there is at least a perceptible
thickening of the periodontal ligament space. In fact,
investigators have demonstrated that lesions of the
medullary bone are likely to go undetected until the
resorption has expanded into and eroded a portion of
the cortical plate.
811
The difficulties and inherent errors in radiographic
interpretation were clearly demonstrated by Goldman
et al.,
12
who submitted recall radiographs of endodon-
tic treatments, for clinical evaluation, to a group of radi-
ologists and endodontists. They assessed success and
failure by observation of radiodensities. There was more
disagreement than agreement among the examiners.
Radiographs are an essential aid to diagnosis but must
be used with discretion. However, radiographs are the
Figure 9-1 Disclosing canals by radiography. A, Right-angle horizontal projection reveals four les in separate canals superimposed. B,
Horizontal angulation varied 30 degrees mesially reveals all four canals and le short of working length in mesiolingual canal (arrow).
Reproduced with permission from Walton RE.
27
A B
Preparation for Endodontic Treatment 359
only method whereby the dentist can visualize that
which he cannot see or feel during the process of diag-
nosis and treatment. He will discover that, as his radi-
ographic techniques and interpretation improve, so will
the ease and success of his root canal treatment. The
techniques outlined in the following sections have
proved to be successful and predictable. If followed, they
will greatly simplify difficulties in root canal treatment.
INSTRUMENTATION
Systems
There are two radiographic approaches. The tradition-
al approach is the x-ray exposure of lm, which is then
chemically processed to produce an image. The newer
digital radiography systems rely on an electronic detec-
tion of an x-ray-generated image that is then electron-
ically processed to produce an image on a computer
screen, an image that is similar in interpretative quality
to the traditional radiograph.
1316
Advantages of digi-
tal radiography include reduced radiation of the
patient, speed of obtaining the image, enhancement of
the image, computer storage, transmissibility, and a
system that does not require chemical processing.
17
Disadvantages are cost and ease of use, although
endodontists are not nding these to be a determent to
their practice, in which speed and the preceding fea-
tures are important. As costs decrease and technology
improves, use of the digital system will undoubtedly
increase by all practitioners. Digital radiography is dis-
cussed in full later in the chapter.
Traditional Machines
Two basic types of x-ray machines are commonly used
in dental offices. One type has a range of kilovoltage
and two milliamperage settings with which the long
(16-inch) cone is frequently used. The other type offers
only one kilovoltage and milliamperage setting and
only the short (8-inch) cone. Either type provides ade-
quate radiographs. However, each has advantages that,
under different circumstances, will yield a more satis-
factory result. The long-cone system is superior for
diagnostic radiographs, whereas the exible short-cone
machine is more appropriate for treatment or work-
ing lms. Any x-ray machine must be properly shield-
ed and collimated by means of a lead diaphragm and
ltered by aluminum disks to ensure proper radiation
safeguards for the patient and professional personnel.
An additional protective measure is the draping of the
patient with a lead apron to block scatter radiation.
Long Cone. Because of the clarity of detail and
minimum distortion inherent in the long-cone parallel
technique,
1821
the long-cone machine is preferred for
exposing diagnostic, nal, and follow-up radiographs.
Short Cone. Because of the number of working
radiographs taken in the course of endodontic therapy,
the practitioner treating more than the occasional
tooth will nd that a short-cone machine, with a small,
easily manipulated head, saves much time, energy, and
frustration (Figure 9-3).
Film. Industrial technological advances have
allowed lm exposure time to be reduced to fractions of
Figure 9-2 Locating canal of the receded pulp. A, Advanced calcication and receded pulp. B, Radiograph reveals angulation of prepara-
tion and canal (arrow) at mesial of cut. C, Canal, seen in radiograph, is discovered with a ne le. (Courtesy of Dr. Steven Koehler.)
A B
C
a second. Recent improvements in emulsion thickness
allow rapid processing of the new lms, which are used
for diagnostic and working lms alike. A study of
Kodak Ektaspeed lm (E lm), which is coated with
larger silver bromide crystals and has one half the expo-
sure time of standard Kodak Ultraspeed lm, concluded
that the Ektaspeed lm had comparable accuracy with
the Ultraspeed lm in measuring root length, even
though the new Ektaspeed is somewhat grainier.
22
A
double-blind study found the slower Ultraspeed lm
superior in terms of contrast, image, quality, and rater
satisfaction.
23
However, a US Army study found both
lms adequate for routine endodontic use.
24
An even faster lm (F speed) has very recently been
introduced. This lm requires 20% less radiation but
appears grainier. There are no published studies to date
on the suitability of this new lm for endodontic use.
For dentists with a referral endodontic practice,
duplicate lm packets are recommended for the diag-
nostic, nal treatment, and recall radiographsone
set for the permanent office record, the other for the
referring dentist. One must know, however, that the
front lm in the double pack, the one closest to the
x-ray machine, had signicantly superior image qual-
ity compared to back lms.
25
The standard periradicular size lm is used for most
situations. In addition, every office should have 2 3-
360 Endodontics
inch occlusal lm available for use when (1) periradic-
ular lesions are so extensive that they cannot be demon-
strated in their entirety on one periradicular lm; (2)
there is interest in or involvement of the nasal cavity,
sinuses, or roof or oor of the mouth; (3) trauma or
inammation prohibits normal jaw opening required to
place and hold a periradicular lm; (4) a handicapped
person is unable to hold a periradicular lm by the
usual means; (5) detection of fractures of the anterior
portion of the maxilla or mandible is needed; and (6)
very young children are being examined.
Film Placement. Film placed parallel to the long
axis of the teeth and exposed by cathode rays at a right
angle to the surface of the lm yields accurate images,
free of shortening or elongation
26
(Figure 9-4). If this
principle is applied, it is unnecessary to memorize xed
cone angulations. In a modern, comfortable operating
chair, moreover, with the patient in a semireclined
position, she need not be returned to an upright posi-
tion for each exposure.
Because of the complicating presence of the rubber
dam, the methods for placement of working lms dif-
Figure 9-3 Working head of the exible, compact, short-cone
x-ray machine, the GX-770, ideal for exposing endodontic work-
ing lms but of adequate quality for diagnostic, archival, or fol-
low-up purposes. (Courtesy of Gendex Corp., USA.)
Figure 9-4 Radiographic parallelism. The long axis of the lm, the
long axis of the tooth, and the leading edge of the cone are parallel
and perpendicular to the x-ray central beam. Reproduced with per-
mission from Goerig AC. In: Besner E, et al., editors. Practical
endodontics. St. Louis (MO): Mosby; 1993. p. 56.
Preparation for Endodontic Treatment 361
fer somewhat from the methods for placement of diag-
nostic, nal, and follow-up lms.
Diagnostic Radiographs. These must be the best
radiographs possible. To achieve this goal, there are
advantages to parallelism, which permits more accu-
rate visualization of structures as well as repro-
ducibility. This facilitates comparison of follow-up
radiographs.
There are a number of devices on the market that
ensure lm placement and parallelism. The Rinn XCP
(Dentsply/Rinn Elgin, Ill.) virtually guarantees distortion-
free lms but cannot be used with the rubber dam in
place. The Rinn Endoray II endodontic lm holder is
designed specically to ensure parallelism yet avoid rub-
ber dam clamps while allowing space for les protruding
from the tooth (Figure 9-5). Film holders are preferred to
nger retention of the lm. A straight hemostat is an
excellent lm holder.
Working Radiographs. One great difficulty in root
canal therapy is the clumsy, aggravating method of tak-
ing treatment radiographs with the rubber dam in
place. Some dentists remove the rubber dam frame for
access in lm placement, and saliva enters to contami-
nate the operating eld. It is therefore imperative that a
lm-placement technique be used so that the rubber
dam frame need not be removed. Use of a radiolucent
N- (Nygaardstby) frame (Coltene/Whaledent/
Hygenic; Mahwah, N.J.), le Cadre Articul-type frame
(Jored, Ormoy, France, or Trophy, USA) (see Figures 9-
57 and 9-58), or the Star VisiFrame (Dentaleze/ Star,
USA) will ensure that apices are not obscured.
With the rubber dam in place, a hemostat-held lm
has signicant advantages over the nger-retained lm:
(1) the lm placement is easier when the opening is
restricted by the rubber dam and frame; (2) the patient
may close with the lm in place, a particular advantage
in mandibular posterior areas where closing relaxes the
mylohyoid muscle, permitting the lm to be positioned
farther apically; (3) the handle of the hemostat is a
guide to align the cone in the proper vertical and hori-
zontal angulation (Figure 9-6); (4) there is less risk of
distortion of the radiograph caused by too much nger
pressure bending the lm; and (5) patients can hold a
hemostat handle more securely with less possibility of
lm displacement. In addition, any movement can be
detected by the shift of the handles and corrected
before exposure.
In all instances of lm placement, the identifying
dimple should be placed at the incisal or occlusal edge
to prevent its obscuring an important apical structure.
Cone Positioning. It is a mistake to rely on only
one lm. There is much to be learned from additional
exposures taken from varied horizontal or vertical
projections.
Vertical Angulation. Ordinarily, it is preferable to
align the cone so the beam strikes the lm at a right
angle. This alignment ensures a fairly accurate vertical
image. Elongation of an image, however, may be cor-
rected by increasing the vertical angle of the central
Figure 9-5 The universal Rinn EndoRay plastic lm holder is
designed for horizontal posterior lms or anterior vertical lms,
maxilla or mandible, right or left. Here it is set for a maxillary pos-
terior view. The cupped-out area accommodates the tooth, clamp,
and extruding endodontic les. The parallel sighting rod/handle
can be moved from right to left. (Courtesy of Rinn Corp., USA.)
Figure 9-6 Working lm properly placed and held under rubber
dam with hemostat. Cone is aligned at right angle to handle.
(Courtesy of Dr. Richard E. Walton.)
ray. Conversely, foreshortening is corrected by decreas-
ing the vertical angle of the central ray. To remember
this, one should think of the sun: it casts a shortened
shadow at noon when it is at its zenith, or increased
vertical angle.
Frequently, an impinging palatal vault prevents par-
allel alignment of the lm and the teeth. However, if the
lm angle is no greater than 20 degrees in relation to
the long axis of the teeth, and the beam is directed at a
right angle to the lm, no distortion occurs, although
there is a less effective orientation of structures.
26
The
resulting radiograph is still adequate.
Horizontal Angulation. Walton introduced an
important renement in dental radiography that has
materially improved the endodontic interpretive
lm.
27
He demonstrated a simple technique whereby
the third dimension may be readily visualized.
Specically, the anatomy of superimposed structures,
the roots and pulp canals, may be better dened.
The basic technique is to vary the horizontal angu-
lation of the central ray of the x-ray beam. By this
method, overlying canals may be separated, and by
applying Clarks rule,
28
the separate canals may then be
identied. Clarks rule states that the most distant
object from the cone (lingual) moves toward the direc-
tion of the cone. Stated in another way, using a help-
ful mnemonic, Clarks rule has been referred to as the
SLOB rule (Same Lingual, Opposite Buccal): the object
that moves in the Same direction as the cone is located
toward the Lingual. The object that moves in the
Opposite direction from the cone is located toward the
Buccal. The SLOB rule, simply stated, is The lingual
object will always follow the tube head. Goerig and
Neaverth cleverly applied the SLOB rule to determine,
from a single lm, from which direction a radiograph
was taken: mesial, straight on, or distal. Knowing the
direction, one is then able to determine lingual from
buccal
29
(Figure 9-7). Stated more simply, Ingles rule is
MBD: Always shoot from the Mesial and the Buccal
root will be to the Distal.
Horizontal Angulation Variations. Mandibular
Molars. As previously emphasized, the lm must be
positioned parallel to the lower arch. The standard
horizontal x-ray projection then is at a right angle to
the lm (perpendicular), as shown in Figure 9-8. The
two mesial canals are superimposed one upon the
other and appear as a single line.
Through the Walton projection, however, the canals
can be made to open up. This is done by directing the
central beam 20 to 30 degrees from the mesial (Figure
9-9, A). In Figure 9-9, B (black arrows), the two canals
in each root can now be readily discerned.
362 Endodontics
The contrast gained by varying the horizontal pro-
jection can best be seen in a clinical case with four
canals. Figure 9-10, A, taken at a right angle, clearly
shows the four instruments superimposed on one
another. Figure 9-10, B, on the other hand, taken from
a 30-degree variance in horizontal projection, empha-
sizes the third dimension: the separation of the instru-
ments in the canals. By applying Ingles rule (MBD:
shoot from the mesial), one also determines that the
buccal canals are toward the distal.
Another point should be made at this time con-
cerning a frequent mistake in reading periradicular
radiographs. It can best be illustrated by a cross-sec-
tional drawing of molar root structure. Roots con-
taining two canals are often hourglass-shaped, as
Figure 9-11, A, indicates. When an x-ray beam passes
directly through this structure, the buccal and lingual
portions of the root are in the same path (arrows).
Because a double thickness of tooth structure is pen-
etrated by the x-rays, it is seen in the lm as a
radiopaque root outline in close contact with the
lamina dura. This is readily apparent on the radi-
ograph (Figure 9-11, B).
By aiming the cone 20 degrees from the mesial, howev-
er, the central beam passes through the hourglass-shaped
root at an angle (Figure 9-12, A). In this case, the two thick-
nesses of the root are projected separately onto the lm.
Since less tooth structure is penetrated by the x-ray, the
image on the lm is less dense. A radiolucent line is clearly
seen in Figure 9-12, B (open arrow). This radiolucent line
can be erroneously read as a root canal. One should take
care to follow up the length of the line. Instead of entering
the pulp chamber, it can be traced to emerge at the gingival
surface of the root. This simple interpretive error can easily
lead to gross mistakes in endodontic cavity preparation.
Mandibular Premolars. The importance of varying
the horizontal angulation when radiographing
mandibular premolars is demonstrated in Figure 9-13,
A, wherein the central ray is directed at a right angle to
the lm. What appears to be a single straight canal is
discernible in each premolar (Figure 9-13, B). There is
an indication, however, in the image of the rst premo-
lar that the canal might bifurcate at the point of the
abrupt change in density (arrow).
Directing the central ray 20 degrees from the mesial in
the rst premolar (Figure 9-14, A) causes the bifurcation
to separate into two canals (Figure 9-14, B). The tapering
outline of the tooth, seen in both projections, would
indicate, on the other hand, that the two canals
undoubtedly rejoin to form a common canal at the apex.
In both the right-angle and 20-degree variance projec-
tions, the second premolar appears as a single canal.
Preparation for Endodontic Treatment 363
Maxillary Molars. Maxillary molars are consistent-
ly the most difficult to radiograph because of (1) their
more complicated root and pulp anatomy, (2) the fre-
quent superimposition of portions of the roots on each
other, (3) the superimposition of bony structures
(sinus oor, zygomatic process) on root structures, and
(4) the shape and depth of the palate, which can be a
major impediment.
As is true of the mandible, the complex root anato-
my and superimpositions may be dealt with by vary-
ing the horizontal angulations. Film placement must
again be parallel to the posterior maxillary arch, not to
the palate.
The standard right-angle projection for a maxillary
rst molar that is illustrated in Figure 9-15, A, pro-
duces the image seen in Figure 9-15, B, wherein the
zygomatic process is superimposed on the apex of the
palatal root (arrow) and the distobuccal root appears
to overlie the palatal root. The sinus oor is also
superimposed on the apices of both the rst and sec-
ond molars.
When the horizontal angulation is varied by 20
degrees to the mesial (Figure 9-16, A), the zygomatic
process is moved far to the distal of the rst molar and
the distobuccal root is cleared of the palatal root
(Figure 9-16, B, arrows).
Figure 9-7 Applying the SLOB rule to determine the direction from which the lm was taken. Anyone knowing the direction can tell lin-
gual from buccal. Clues that the lm is taken from the mesial: A and B, The mesial-buccal (MB) root lies over the palatal (P) root, that is,
the lingual (palatal) root has moved mesially; the lingual arm of the rubber dam clamp (arrow) has moved mesially. The canine is visible.
Once it has been determined that the radiograph was taken from the mesial, the lingual root (toward the mesial) of the premolar is dened.
C and D, Radiograph of the same teeth taken from the distal. Clues are reversed. There is no canine visible in the lm, and the lingual pre-
molar canal is now toward the distal. Reproduced with permission from Goerig AC. In: Besner E, et al., editors. Practical endodontics. St.
Louis (MO): Mosby; 1993. p. 54.
A
B
D
C
364 Endodontics
Figure 9-9 Mandibular molars. A, Central ray directed at 20 degrees mesially to lm positioned parallel to arch. B, Two canals are now visible in
both roots of the rst molar (black arrows). Open arrow indicates confusing root outlines. Reproduced with permission from Walton RE.
27
Figure 9-10 Mandibular molars. A, Right-angle horizontal projection superimposes four les, one on the other. B, Horizontal variance of
30 degrees separates four canals. SLOB rule proves lingual canals are to the mesial. Reproduced with permission from Walton RE.
27
Figure 9-8 Mandibular molars. A, Central ray directed at right angle to lm positioned parallel to arch. B, Limited information is gleaned
from radiograph because of superimposition of structures and canals. Reproduced with permission from Walton RE.
27
Preparation for Endodontic Treatment 365
The opposite projection also can be used to isolate
the mesiobuccal root of the rst molar, that is, the cen-
tral ray may be projected from 20 degrees distal to the
right angle (Figure 9-17, A). Although this projection
distorts the shape of the mesiobuccal root, it also iso-
lates it (Figure 9-17, B), so that the canal is readily dis-
cernible (arrow). Also note that the zygomatic process
is moved completely away from any root structure,
including the second molar.
The same technique illustrated here for the maxil-
lary rst molar can be applied to the second or third
molars by directing the central beam at a horizontal
variance through those teeth.
Maxillary Premolars. Variance in the horizontal
projection has great value in maxillary premolar radi-
ography, particularly for the rst premolar, which
generally has two canals, but sometimes three. The
clinical efficacy of the Walton technique is well illus-
trated in Figure 9-18. The right-angle horizontal pro-
jection produces the single canal image seen in Figure
9-18, A. By varying the angulation by 20 degrees,
however, the two canals are separated (Figure 9-18,
B), giving an unobstructed view of the quality of the
llings in both canals.
Mandibular Anterior Teeth. Aberrations in canal
anatomy in the mandibular anterior teeth are infa-
mous. Variance of the horizontal x-ray projections in
this region will bring out the differences. Figure 9-19,
A, illustrates the standard x-ray projection bisecting the
lm held parallel to the arch. The incisor teeth appear
Figure 9-12 A, X-ray beam aimed 20 degrees mesially passes through single thicknesses of hourglass root, leaving less dense impression on
lm. B, Radiolucent line is apparent (open arrow) and may be confused with root canal. Note that it emerges at gingival, not into pulp cham-
ber. Black arrows indicate regular canals. B reproduced with permission from Walton RE.
27
Figure 9-11 A, X-ray beam passing directly through two thicknesses of root structure presents intensied image on lm. B, Note
radiopaque root outline inside lamina dura. B reproduced with permission from Walton RE.
27
to have single canals. But a broad single canal is seen in
the distorted canine image (Figure 9-19, B).
By varying the lm placement and projecting directly
through the canine, as seen in Figure 9-20, A (which is
about 30 degrees variance for the incisors), separate canals
appear in the incisors (Figure 9-20, B, arrow) and are then
seen to coalesce at the apex. This would be expected, how-
ever, when one views the tapered incisor roots seen in
both horizontal projections, roots far too narrow to sup-
port two separate canals and foramina. Once again, the
abrupt change in canal radiodensity in the premolars
(arrow) should make one suspicious of canal bifurcation,
a fact that has already been conrmed in Figure 9-14, B.
Maxillary Anterior Teeth. Although canal or root
aberrations appear less frequently in the maxillary
anterior teeth, root curvature in the maxillary lateral
incisors is a particularly vexing problem. Grady and
366 Endodontics
Clausen have shown, for example, how difficult it is to
determine when foramina exit to the labial or lingual.
30
Their radiographs of extracted teeth matched with
photographs of instrument perforation short of the
apex are a warning to all (Figure 9-21).
Processing. Another deterrent to full endodontic
utilization of radiography has been the length of time
required in most offices to process lms. Old, weakened
solutions greatly increase the time required for process-
ing. Moreover, adherence to the manufacturers recom-
mended temperature and time (68F for 5 to 7 minutes)
for developing and clearing has retarded on-the-spot
processing and viewing in most busy practices.
Ingle, Beveridge, and Olson demonstrated, in a
well-controlled blind study, the effects of varied pro-
cessing temperatures. A processing temperature of 92F
yielded, in less than 1 minute, the most acceptable
Figure 9-13 Mandibular premolars. A, Central ray directed at right angle to lm positioned parallel to arch. B, Radiograph reveals one canal
in each premolar, although abrupt change in density (arrow) may indicate bifurcation. Reproduced with permission from Walton RE.
27
Figure 9-14 Mandibular premolars. A, Central ray directed at 20 degrees mesially to lm, parallel to arch. B, In rst premolar, two canals
that are clearly visible (arrow) probably reunite, as indicated by sharply tapered root. Reproduced with permission from Walton RE.
27
A
B
Preparation for Endodontic Treatment 367
Figure 9-15 Maxillary molars. A, Central ray is directed through maxillary molar at right angle to inferior border of lm. Arrow and dot-
ted line passing through malar process indicate it will superimpose over rst molar. B, Superimposition of rst molar roots, sinus oor, and
malar process (white arrow) confuse the diagnosis. Reproduced with permission from Walton RE.
27
Figure 9-16 Maxillary molars. A, Central ray directed at 20 degrees mesially skirts malar process, projecting it distally. B, Distobuccal root
is cleared of palatal root and malar process is projected far to distal (white arrow). Between right-angle and 20 degrees projection, all three
roots are clearly seen. Reproduced with permission from Walton RE.
27
Figure 9-17 Maxillary molars. A, Central beam projected 20 degrees from the distal. B, Mesiobuccal root of the rst molar is isolated (black
arrow) and second and third molars are cleared of malar process, which is projected forward (white arrow). Sinus oor may be lowered or
raised by changing vertical angulation. Reproduced with permission from Walton RE.
27
radiographs.
31
A group of 37 physicians and dentists
selected as best the lms developed at 92F from a
coded selection of lms processed at 4F intervals in the
range of 68 to 100F. At 92F, using Kodak developer
and xer mixed to company specications, develop-
ment required only 30 seconds and xation required
25 to 35 seconds, with no loss of quality.
By comparison, the 70F temperature, recommend-
ed at that time by the manufacturer, required 5 minutes
developing time and 10 minutes xing time for
Ultraspeed lm. Ektaspeed is slightly better: 72 to 80F
for 2
1
2 to 4 minutes developing and 2 to 4 minutes x-
368 Endodontics
ing time. Finally, all lms need to be nal washed for at
least 30 minutes.
In a practice limited to endodontics only, small
quart-size tanks are adequate and economical.
Frequent change of solutions is recommended.
Rapid Processing. Concentrated rapid-processing
chemicals, such as Kodaks Rapid Access solution, have
become very popular in endodontic practice.
Although they are more expensive ounce for ounce,
they save measurable time, requiring only 15 seconds
developing and 15 seconds clearing time in the xer at
room temperature.
Figure 9-18 Maxillary premolars. A, Horizontal right-angle projection produces illusion that maxillary rst premolar has only one canal.
B, Varying horizontal projection by 20 degrees mesially separates two canals. Lingual canal is toward mesial. Reproduced with permission
from Walton RE.
27
Figure 9-19 Mandibular anterior teeth. A, Film placement for bisecting-angle technique. Horizontal central beam projection at right angle
to lm. B, Single canals seen in central incisors with only suggestion of two canals in lateral incisor. In distorted image of canine, note broad
labiolingual canal dimension (arrow). Reproduced with permission from Walton RE.
27
Preparation for Endodontic Treatment 369
A Tel Aviv/UCLA study tested four rapid-developing
solutions, processing both Ultraspeed and Ektaspeed
lms. Film fog became a problem as the solutions deteri-
orated with time. Kodak Rapid Access had to be changed
every day, whereas the other solutions, Colitts (Buffalo
Dental; Syosset, N.Y.), IFP (M & D International), and
Instaneg (Neo-Flo, Inc., USA), would deteriorate over
60 days. They also found that precise developing time and
3 to 5 seconds rinse time between developing and xing
are absolutely essential.
32
Figure 9-20 Mandibular anterior teeth. A, Film is positioned for canine radiograph using bisecting-angle technique. Horizontally, central
beam is projected at right angle to lm. B, Canine image is single straight canal, but incisor image reveals bifurcated canals that reunite in
narrow tapered root (arrows). Note bonus image of bifurcated canals, rst premolar. Reproduced with permission from Walton RE.
27
Figure 9-21 A, Labiolingual projection
through canine shows instrument apparently at
apex with slight distal curvature. B, Mesiodistal
projection reveals instrument actually emerging
from labial short of apex. C, Instrument perfo-
rating foramen to labial well short of radi-
ographic root end. (Courtesy of Dr. John R.
Grady and Dr. Howard Clausen.)
Warning: These rapidly processed lms will fade or
discolor with time.
33,34
This change can be prevented,
after viewing, by returning the wet lm for a few min-
utes of xation, followed by washing for 30 minutes,
and then drying. The lms will then retain their quali-
ty indenitely.
Table-Top Developing. For really rapid response
and ease of processing, combining rapid-speed solu-
tions with a table-top processing hood (Figure 9-22)
greatly improves radiographic reporting, particularly
working lms. These hoods are often used right in the
operatory. The operator places his hands through light-
proof cuffs and observes hand movement inside the
hood through the red Plexiglas cover. The rapid solu-
tions and rinse water can be in small cups no deeper
than a periradicular lm (see Figure 9-22).
Direct Digital Radiography
As dentistry parallels photography, in the move from
silver halide lm to digital photography and comput-
er processing, the profession will undergo continued
growth toward digital radiographic systems. Digital
radiography used in dentistry is available in three
variations: direct digital, storage phosphor, and indi-
rect digital.
The direct digital systems use a solid-state sensor
such as a charge coupled device (CCD) similar to the
chips in home camcorders. These systems have a cable
that connects the sensor to the computer and in turn to
the screen monitor (Figure 9-23).
The storage phosphor systems use a photo-stimula-
ble phosphor plate that stores the latent image in the
phosphor for subsequent readout by an extraoral laser
scanner (Figure 9-24).
Indirect digital systems use a scanning device con-
nected to a computer for digitizing traditional silver
halide dental lms.
In clinical endodontics, the most applicable technol-
ogy is the direct digital (wired) type of digital radi-
ographic system. In a general practice, however, it can
be advantageous to have the lm-scanning capability.
Direct digital radiography (DDR) is the direct
replacement of an x-ray lm with an electronic image
receptor or sensor and an image displayed on a com-
puter (see Figure 9-23). In traditional dental radiogra-
phy, as in photography, lm is used to capture an image
on a chemical emulsion. In the last 10 years, however,
photo lm is being replaced by the electronic digital
camera. The CCD technology, used in digital cameras
and camcorders, has been adapted for intraoral cam-
eras and radiography. Both of these technologies share
the same underlying operating principles.
370 Endodontics
DDR makes use of a rigid solid-state sensor, typical-
ly a CCD, a complementary metal oxide silicon, or a
charge injection device, connected by a cable to a com-
puter, a monitor, and a printer. The typical DDR sensor
is packaged in a hard aluminum or plastic shell that
encases several components (Figure 9-25). X-radiation
(light), generated from any modern x-ray head, is con-
verted by a screen to green light that is transmitted
through an optical ber to the CCD sensor. The CCD
Figure 9-22 Counter-top x-ray developing hood along with rapid
developer/xer, solution cups, and single lm holders. Light-tight
handholes and lightproof lid for viewing. (Courtesy of Densply/
Rinn Corporation.)
Figure 9-23 Digital radiography. VIXA intraoral sensor against
the video screen showing last image in place. The sensor should be
covered with a rubber nger-cot to preserve sterility.
Preparation for Endodontic Treatment 371
then converts the green light to electrons that are
deposited in electron wells for subsequent readout, line
by line by the electronics.
3537
The most signicant advantage to the DDR-style
devices is the near instantaneous (a few seconds) avail-
ability of the images after exposure without removing
the sensor from the mouth.
This allows multiple angles to be taken to help in
location of canals, identication of root curvatures,
verication of working lengths, and verication of
intermediate obturation results. Treatment delays
caused by missed apices, cone cuts, and poor exposure
are reduced from several minutes to seconds. This can
be accomplished with one half to one-eighth of the
radiation normally used in exposing a single silver
halide dental lm.
Tangible Benets. There are several immediate
benets to using DDR for endodontic procedures. No
darkroom or processing equipment is needed.
Infection control procedures are reduced, and dupli-
cates are instantly made with absolutely no loss in
image quality. Additionally, the sensitivity of the recep-
tors and the digital nature of the image permit reduc-
tion of the patients x-ray exposure. Computers can be
used to store and enhance the image or to transmit it
over a telephone line to an insurance company or to a
colleague for instant consultation. Most important is
the trust and credibility gained by displaying a huge
image that the patient can see and understand, using a
familiar delivery mediuma TV picture (Figure 9-
26). The radiographic picture on the computer screen
helps the clinician explain needed treatment. This is
particularly important for specialists as they may have
only one or two visits to gain the patients trust,
explain the need for treatment, obtain informed con-
sent, and complete their care.
Time Savings. Time saved by not waiting for lm
processing is certiable with digital radiography.
Automatic chemical processing takes 4 to 6 minutes,
whereas the slowest digital system takes only 7 seconds.
Yet this does not tell the whole story. The real time for a
radiographic event is measured from the time the cli-
nician rst prescribes the radiograph until the time the
image is ready for viewing. The assistant must drape the
patient with the lead apron and position the sensor or
lm, which takes a few minutes. Then the lm is
removed from the mouth, chemically processed, rinsed,
and dried. Thus the real time for lm radiography is
about 6 minutes, whereas digital radiography is closer to
Figure 9-24 DenOptix Storage Phosphor system from Gendex
with laser scanner. (Courtesy of Dentsply/Gendex.)
Figure 9-25 Trophy sensors. Clockwise from x-ray lm (right),
DMD size #1, DMD size #2, Trophy Universal. (Courtesy of John A.
Khademi.)
Figure 9-26 The patient can readily see her clinical situation on
the computer screen. (Courtesy of John A. Kahdemi.)
3 minutes, including the draping. With DDR, however,
there is no dead time during the radiographic event
and no need to mentally re-enter the case.
Retakes. Ease of retakes is often overlooked when
discussing time savings. Ease of retakes is the real time
saver. With lm, a retake requires another 6 minutes or
more, whereas with digital, a retake takes an instant. An
even greater benet is that the x-ray head, patient, and
sensor are all still in place. This simplies interpreta-
tion and adjustment to different angles. There is no
need to remember the case or wonder at what angle
the last radiograph was taken.
Dose Reduction. Lower x-ray dosage is another
quantiable benet of all digital radiography systems.
Almost all of the digital systems are capable of reduc-
ing exposure to 50% of conventional E-speed lm.
Exposure can be further decreased to less than 20% if
image quality is slightly compromised. This is accom-
plished by underexposing the sensor and then using
the computer-processing functions to visually improve
the image quality.
With the growing concern of patients regarding
radiation exposure, digital systems help defuse their
concerns about radiography.
Computer Processing. Although the software pro-
grams provided with the different digital radiography
systems have a dazzling array of image-processing algo-
rithms, only a few are of primary importance in
endodontics. The most important image-processing
tool is the brightness/contrast tool. Images that are
washed out or underexposed can often be computer
processed to increase their contrast and decrease the
brightness (Figure 9-27). However, as useful as this tool
is, it cannot correct a badly overexposed image because
372 Endodontics
the pixels have been saturated, and no recovery can be
made other than re-exposing the sensor.
From a patient education perspective, another com-
puter enhancement that is quite useful is the Pseudo-
3D feature shown in the Trophy software (Figure 9-
28). The radiograph is converted to a contour map
while maintaining the relative gray levels. The radiolu-
cency at the periapex of the tooth is dark, relative to the
surrounding structures, and thus appears as a hole in
the bone in the Pseudo-3D view. This allows the clini-
cian to communicate, in a more understandable man-
ner, the loss of periapical bone.
Digital Radiographic Technique for Endodontics
The assistant enters the patients demographics into the
computer and selects the exam type from the menu
that appears on the screen. The sensor is then sheathed
in a latex nger cot (for sanitary reasons) (Figure 9-
29) and correctly positioned intraorally. The x-ray head
is then positioned, the computer software is activated,
and x-ray exposure is made. The computer has cap-
tured and stored the image as it appears on the moni-
tor screen (Figure 9-30). If adjustments are needed, the
sensor and/or the x-ray beam (head) may be reposi-
tioned while the sensor is still in place. Again, the cor-
rected image appears on the screen to guide the dentist
and/or instruct the patient. All of the images will be
stored and may later be recalled to complete the
patients record. The before and after images can then
be transported by hard copy or electronic mail to the
referring dentist.
Tooth Length Measurement. The ability to accu-
rately measure preoperative working length is another
useful tool. Since the pixel sizes making up the digital
Figure 9-27 Computer processing to enhance image. Left, Slightly underexposed, unprocessed image. Right, Computer-processed image
highlights resorptive defect over the distal root. (Courtesy of John A. Kahdemi.)
A B
Preparation for Endodontic Treatment 373
image are known, it is easy for the computer to calcu-
late a preoperative length, even around curvatures.
(Figure 9-31). Most digital radiography programs
allow the clinician to start at either the coronal or api-
cal reference point and enter (by clicking a mouse)
several points along the anticipated canal path. These
preoperative lengths are within 0.5 mm more than
95% of the time.
Sensor Sizes. Endodontic imaging needs can be
met by a single sensor size. Generally, the smaller sen-
sor size (size 1 equivalent) is the most useful in an
endodontic setting (see Figure 9-25). The smaller size is
more comfortable for the patient and easier for the
assistant to place. The larger sensors can be more diffi-
cult to place because of their rigidity. An extra sensor
should be available in the event of sensor failure.
Holders. Properly designed paddle-style holders
greatly facilitate infection control procedures. Correct
sensor positioning and angulation lead to better
images. These holders can be easily bent to manage
tipped and rotated upper and lower molars. Snap-A-
Ray and Rinn Endoray II-style holders can also be
Figure 9-28 Computer enhancement using
Pseudo-3D feature of Trophy software that
converts a traditional two-dimensional radi-
ograph into a third-dimensional contour
map that is better understood by the patient.
Note the periapical lesion as a dark hole.
(Courtesy of John A. Khademi.)
Figure 9-29 For sanitary reasons, the sensor is sheathed in a latex
nger-cot. (Courtesy of John A. Khademi.)
used, but they are bulkier and harder to sheath.
Occasionally, the aiming guides are in the way during
angled radiography or interfere with the rubber dam.
Exposure. There is considerably less latitude with
regard to correct exposure with digital systems than with
lm. Although this may seem counterintuitive, given
that the digital images can be reprocessed, overexposure
results in permanent loss, on the screen, of anatomic
structures. With digital images, one should err on the
side of underexposurethe opposite of lm images.
Additionally, some x-ray heads do not have a low
enough setting; to further decrease exposure, the x-ray
head is moved away from the patient by 6 to 12 inches.
Buyers Guide
The prime technical factors to consider in the purchase
of a digital radiography system for use in endodontics
are the ease of use of the software and the availability of
appropriately sized sensors, a sensor replacement war-
ranty, and efficient holders. Multiple image processing
and enhancement tools, although appealing, contribute
little to the day-to-day use of the system and can often
be in the way. The differences in image quality between
the present systems are relatively narrow.
Computer Systems. This new technology to
replace lm requires a Windows NT or Windows 2000
server with Fault-Tolerant hard drives (RAID).
Uninterruptible power supplies should be installed on
the server and all clinical workstations. Images should
be automatically backed up and stored off-site.
Monitors. Large, high-quality computer monitors
allow maximum resolution of the image to be displayed
374 Endodontics
as well as the ability to display multiple images. Larger
monitors are often brighter, which allows for easier
interpretation in the well-lit dental operatory. Flat pan-
els or liquid crystal displays are becoming increasingly
popular as the dental operatory becomes starved for
space. One would be well advised, however, that some
at panels have very limited viewing angles, and the
image is almost invisible when viewed off-angle.
FUTURE TRENDS
Digital Subtraction Radiology
Digital Subtraction Radiology (DSR) uses a computer
to assess, in two or more radiographs, pathologic
changes that have taken place over a period of time.
With conventional radiography, detection of a change,
such as an increase or decrease in lesion size, is done by
viewing two lms, side by side, on a view box.
Unfortunately, this is a very insensitive technique for
detecting small bony changes. With conventional radi-
ography, a 30 to 50% radiodensity difference is needed
for reliable detection of change, and cancellous bone
changes may not be visible at all.
9
DSR can signicant-
ly improve ones diagnostic accuracy of periapical
lesions, allowing for earlier intervention and more
accurate detection of active disease.
3842
Figure 9-30 All of the radiographic images are stored in the com-
puter and may be called up at any time for diagnosis, patient edu-
cation, or printing. (Courtesy of John A. Khademi.)
Figure 9-31 By beginning at the apex and advancing the cursor
toward the crown with the mouse, the computer will accurately
calculate the working length of the tooth in millimeters, even
around curvatures. (Courtesy of John A. Khademi.)
Preparation for Endodontic Treatment 375
To use the DSR technique, the two digital images to
be compared are brought into the computer software.
Since they are digital images, they are stored in a
numeric format in the computer memory and can be
compared mathematically. Typically, the background
images that have not changedcrowns, llings, and so
forthare subtracted, which in turn highlights areas
that have changedlesion size and/or density, for
instance.
43
Tomography
Another exciting development is the generation of den-
tal tomographic images
44
(E Hebranson and P Brown,
personal communication, 1999). Tomography is a radi-
ographic technique that essentially slices the teeth
into thin sections. Computers then reassemble the sec-
tions to generate a three-dimensional image. When
these techniques are rened, pulp spaces and roots will
be visualized in the third dimension. Buccolingual cur-
vatures will be evident, as well as the shape of the canal
space and the location of the apical foramen (Figure
9-32). An additional advantage would be the elimina-
tion of specialized angled radiography; all angled views
will be simultaneously captured in one exposure.
RADIOGRAPHIC INTERPRETATION
Since properly positioned, exposed, and processed
radiographic or digital images (Figure 9-33) are of
value only if they are properly interpreted, every advan-
tage must be taken to obtain the most information
from the image. For the student and seasoned practi-
tioner alike, a good magnifying glass has often brought
to light an extra root, root canal, or hard-to-nd apex.
A superlative method for examining radiographs is
the Brynolf magnier-viewer.
45
This device enhances
the viewing of individual lms in two ways: the image
is magnied several times, and all peripheral light is
effectively blocked out. Masking the light source
around a radiograph greatly increases the ability of the
viewer to distinguish grades of density.
46
A lm that
has been slightly overexposed, if magnied and
inspected over a strong light, yields a remarkable
amount of unsuspected information. In a re-treated
case, endodontic success had been denied for 9 years
until inspection under magnication of the original
radiograph disclosed a previously overlooked third
root on a maxillary rst premolar.
Many departures from classic radiographic proce-
dures have been strongly advocated for endodontic
Figure 9-32 Tomographic images of a maxillary molar reconstructed by computer. Tomography essentially slices the image into thin sec-
tions and then reassembles them into a three-dimensional image. A, Buccal view. B, Mesial view. (Courtesy of John A. Khademi.)
A
B
therapy. Any variation that makes the exposure and
processing of radiographs easier, faster, and better, and
the interpretation more thorough, increases the value
of these eyes beneath the surface. It is when we do not
see what we are doing that failures increase.
VISUAL ENHANCEMENT
Endoscopy
Light and magnication are key factors in endodontics
because what cannot be seen cannot be properly treat-
ed. The Endoscope (Karl Storz, Germany/USA) and the
Orascope (Sitca, Inc., USA) provide both light and
magnication for better access and location of canal
orices, fractures, failing silver points, separated instru-
ments, and posts. They are also extremely useful in
endodontic surgery, including apicoectomy, retroll-
ings of the root end, location and repair of perfora-
tions, and internal and external resorptive defects.
Endoscopy is the inspection of body cavities and
organs using an endoscope. This device consists of a
tube and an optical system with a high-intensity light.
The image captured by the endoscopic camera is pro-
jected onto a video monitor for viewing (Figure 9-34).
In endodontics, one can visualize access openings,
canal orices (Figure 9-35), the canal interior, frac-
tures, resorptive defects, and surgical sites, all highly
magnied.
Endoscopy dates back to the time of Hippocrates II
(460375 BC) when physicians of the time used tubes
inserted into body openings to view interior structures.
376 Endodontics
Abulkasim, in AD 1012, used a mirror to reect light
through the hollow tube. Aranzi, in 1585, used reect-
ed solar rays to peer into nasal cavities. Bonzzani
(1804) used a candle as a light source, and Segalas in
1826 added a cannula for ease of insertion.
Desormeaux (1835) is considered the father of
endoscopy, using kerosene lamplight reected through
a mirror system. He used this system as a cystoscope
and a urethroscope. Panteleone (1869) rened the
Desormaux scope for looking into the uterus. In 1877,
Nitze added an optical lens system to the tube. Dittel
(1887) added a small incandescent bulb at the end of a
cystoscope as a light source. (Thomas Edison invented
the incandescent lamp in 1880.) By the end of the nine-
teenth century, there existed cystoscopy, proctoscopy,
laryngoscopy, and esophagoscopy. In 1901, Ott was the
rst to make a small incision into the abdomen and use
a mirror head to reect light. Also in 1901, Kelling
injected air through a separate needle during a cysto-
scopic procedure in a dog as the rst closed endoscop-
ic procedure. Takagi (Tokyo 1918) was the rst to
examine the knee joint. In 1952, Hopkins used quartz
rods in the tube of the scope to project light into the
operating eld, and in 1968 ber optics were added,
and the system that is used today came into being.
47
The rst use of the endoscope in endodontics was to
observe fractures in teeth.
48
Held et al.
49
and Shulman
and Leung
50
in 1996 reported the use of the endoscope
for both conventional and surgical endodontics.
Bahcall et al. recently described using the endoscope
Figure 9-33 A, Poorly processed radiograph lacks denition for proper diagnosis. B, Properly processed radiograph of same case yields
diagnostic details lacking in A. (Courtesy of A. C. Goerig and E. J. Neaverth.)
A B
Preparation for Endodontic Treatment 377
for increased magnication and visualization during
endodontic microsurgical procedures.
51
There are many advantages to using the endoscope
in endodontics: direct illumination of the eld, bright-
ness with no loss of resolution, and the ability to view
inaccessible areas by seeing around corners and
beneath and behind areas. The endoscope may be easi-
ly positioned 0.5 to 10 mm from the working eld,
where it will remain in focus. There is also a short
learning curve of 2 weeks to 3 months, no eyestrain,
freedom of body movement, and no need for the use of
a mirror to reect the image as is needed with the sur-
gical microscope.
Magnication can be from 10 to 50 times the origi-
nal, depending on the equipment. The endoscope is
also cost effective compared with the microscope. It is
easily transportable on a cart (see Figure 9-34) and can
also be used as an intraoral camera. Both the dentist
and assistant have full view of the operating eld on
the television monitor. Either the dentist or the assis-
tant can hold the scope in place while the procedure is
being performed.
There are few disadvantages to the endoscope. The
operating eld is not seen in three dimensions; howev-
er, this has not been shown to be an important limiting
factor in either medical or dental endoscopy.
Inadvertent damage to the quartz rods inside the scope
can occur. A nonbendable sheath covering the scope is
used to create rigidity and protect the rods from dam-
age. The scope can be scratched by burs or various
instruments if the tip of the scope is held in very close
proximity to the operating eld. However, these are
unusual occurrences because the endoscope can be eas-
ily positioned so that it is not in direct proximity to the
eld of operation.
The equipment that makes up the endoscope sys-
tem is the endoscope itself, a camera coupler/lens, a
video camera, ber-optic cables to carry light from a
halogen or xenon light source, a camera control unit, a
video recorder and/or a video color printer, and a
video monitor to view the procedure (Figure 9-36).
Although the video recorder and printer are not nec-
essary for operation of the endoscope, they are useful
for documentation and patient education.
Furthermore, an endodontist may send a referring
dentist a color print of a completed surgical procedure
instead of, or along with, a radiograph.
Figure 9-34 Endoscope set-up on mobile cart. Top shelf, Monitor,
and to the right, camera head with scope attached. Middle shelf,
Xenon light source on top of Telecam, the camera control unit,
which is the heart of the system attached by cable to the camera
scope above. Bottom shelf, Color printer. (Courtesy of Karl Storz &
Co. Germany/USA.)
Figure 9-35 A 1.8 mm ber-optic probe examination of the pul-
pal oor, revealing orices of ve canals of mandibular rst molar.
(Courtesy of J. K. Bahcall and J. T. Barss.)
Endoscopes for endodontics can be obtained in 4-
and 8-inch lengths. The tube of the working end of the
endoscope contains quartz rods, some of which bring
light into the eld of operation and some of which
return the image to the camera that projects the image
onto the video monitor. The working end of the scope
can be obtained in a wide variety of angulations: 0, 30,
45, 90, and 135 degrees. The most useful endoscope for
endodontics is the one having a 30-degree angle.
The endoscope comes in a variety of widths, from
0.7 to 10 mm. The most useful width for endodontic
surgical procedures is 4 mm, and for conventional
endodontic treatment, a 0.7 to 4 mm scope is best.
The source of light is delivered to the scope by ber-
optic cables. Hundreds of glass bers are bundled
together to carry light to the quartz rods inside the
scope. Light can come from either a halogen or a xenon
source. A halogen light will provide from 150 to 300
watts of illumination with a slightly yellow hue. A
xenon light source at 300 watts will provide light with
a white hue that will have greater consistency and
brightness. The xenon light is also more penetrating
than is the halogen.
The camera coupler/lens attaches to the end of the
scope. The coupler can be equipped with a zoom con-
trol that allows a closer view in the form of a zoomed
picture that will usually ll the entire monitor screen.
Cameras are produced in one- and three-chip mod-
els. A one-chip camera will deliver 450 lines per second
of image to a video monitor. A three-chip camera deliv-
378 Endodontics
ers 800 lines per second. For comparison, a standard
television delivers 265 lines per second. For endodontic
procedures, at this time, a one-chip camera will pro-
vide sufficient denition and clarity.
The camera control unit controls color density and
shutter control. Automatic gain control ensures clarity
of the picture. The signal degenerates with a longer
cable and the devices (video recorder and printer)
through which the signal has to travel before it reaches
the monitor where it can be viewed. Any size monitor
can be used; however, as the screen increases in size, the
sharpness of the image decreases.
A video recorder can be used to capture an
endodontic procedure. The best quality image for ana-
log video is the Hi 8 system. The highest quality image,
however, is recorded by using a digital video recorder,
wherein the images can be edited and copied multiple
times, with no loss of resolution, as will occur with an
analog system.
50
Stability of the scope itself is important. A variety of
sheaths inserted over the tube of the scope are used to
provide rigidity, support, and stability. They also pro-
tect the tip from potential damage from instruments.
Shulman has described a stabilization technique for
endodontic surgical procedures. He suggests placement
of the end of the rigid sheath on the surface of the
bone, adjacent to the surgical site, thus producing a sta-
ble video image.
50
The sheaths come with a variety of working ends.
Canal orices, calcied canals, perforations, and
resorptive defects can be viewed using a forked-ended
sheath that can rest on access openings, a marginal
ridge, or the buccal or lingual surface of the tooth being
treated or an adjacent tooth (Figure 9-37, A). Sheaths
with retractors that have serrated ends that are a simi-
lar shape to that of a handheld retractor can be
anchored on bone to provide support and ap and
cheek retraction during surgery (Figure 9-37 B). A
sheath shaped like a tongue retractor is used to move
the patients tongue aside while viewing the lingual
aspect of a tooth. The scope can be anchored in posi-
tion by the sheath and the lens/camera coupler can
then be rotated 360 degrees to completely view all
aspects being treated.
During procedures involving rotary instruments, the
tip of the endoscope can become covered with debris
and the video picture can become blurred. Saline in a
syringe or sterile water from a triplex or Stropko
syringe (see chapter 12, Endodontic Surgery) can be
used to rinse away the debris and clear the viewing eld
on the monitor. A cotton swab saturated with saline
solution can also be used to accomplish debris removal.
Figure 9-36 The Endoscope System. The Scope, surveying tooth,
contains quartz rods that convey the image. They, in turn, are sur-
rounded by a ber-optic light source. The Scope is attached to the
camera by a camera coupler, which in turn connects to the com-
puter and printer as well as to the monitor. Images appear on the
monitor and are stored in the computer for later printing if desired.
(Courtesy of F. H. Kahn and B. B. Shulman.)
Preparation for Endodontic Treatment 379
After use, the sheaths should be placed in an ultra-
sonic cleaner to remove debris and sterilized in an auto-
clave with ethylene oxide or glutaraldehyde. The scope
cannot be placed in an ultrasonic cleaner but can be
easily cleaned by soaking in an enzymatic cleaner or
washed gently with soap and distilled water and then
sterilized in glutaraldehyde for 12 hours. Autoclavable
scopes are also available. The lens head/camera coupler
can be cleaned with a mild soap and distilled water and
sterilized by soaking in glutaraldehyde. It is best pro-
tected with a disposable plastic tubewrap during use
to keep it sterile and free of debris.
The Orascope (Sitca, Inc., USA) is an evolutionary
extension of dental endoscopy: Orascopy. Currently,
there are two diameter sizes of exible ber-optic
probes: the 1.8 mm and the 0.7 mm (Figure 9-38) The
1.8 mm probe has 30,000 bers and the 0.7 has 10,000.
A ring of light transmitting bers surrounds the visual
bers (Figure 9-39). Both probes have a large depth of
eld and do not need to be refocused after the initial
focus. The 1.8 mm probe is used to visualize conven-
tional and surgical sites.
51
The 0.7 mm probe is used
for that and for intracanal visualization as well (Figure
9-40). Canal cleanliness, location of accessory canals,
perforations, broken instruments, and resorptive
defects are easily examined.
52,53
The 0.7 mm probe
must be used in a dry canal. It will not penetrate blood,
exudate, or irrigant. The coronal two-thirds of the
canal should be ared to at least a size 70 instrument.
Jedmed is planning to release an endoscopic system
called Endodontic Endoscopic Systems (E.E.S.).
Future Possibilities
Many advances being made in medical endoscopy can
easily be adapted to endodontic endoscopic procedures.
Software can piece two-dimensional images together to
create a virtual three-dimensional y-through. Virtual
reality technique training will enhance and speed the
learning curve for difficult endodontic procedures.
Video and audio conferencing using a webcam, which is
an endoscope to project video images, digital radi-
ographs, and patient les, can be sent over the Internet
so that dentists anywhere in the world are able to confer
and obtain the best diagnosis and treatment planning
for their patients. Future possibilities are unlimited.
SPECIALIZED ENDODONTIC INSTRUMENTS
AND EQUIPMENT
The lack of proper equipment is a reason often given
by dentists who do not practice root canal therapy, and
it well might be. Not only are special instruments
imperative for endodontic treatment, but a special
arrangement of these instruments is necessary.
Figure 9-38 Unsheathed Orascopic ber-optic probes in two
sizes: a, 0.7 mm, and b, 1.8 mm. (Courtesy of Sitca, Inc., USA.)
Figure 9-37 Protective metal sheaths that slip over the scope
provide rigidity and allow the scope to be held in a stable position.
A, Fork-ended sheath fashioned to rest on access openings and/or
marginal ridges. B, Sheaths with serrated ends are used as retrac-
tors anchored in bone. Stability provides constant focus. (Courtesy
of B. B. Shulman.)
Figure 9-39 Cross-section of Orascopic probe showing the distri-
bution of the ber-optic image bundle and the light transmission
bers. (Courtesy of Sitca, Inc., USA.)
Impractical, inefficient scurrying around the office to
gather together a collection of unsterile, ill-adapted
equipment completely discourages the practitioner
from endodontic therapy. These problems may be
solved by procuring the correct equipment and sup-
plies; by packaging the hand equipment into sterilized
towel kits, into canisters, or on prearranged trays; and
nally, by storing the small endodontic instruments in
an organized, compartmentalized instrument case.
Sterilized Towel Kit
Standard dental instruments, along with a few special
instruments necessary for root canal therapy, are
wrapped into a pack in two layers of towel and fastened
with a bankers pin or autoclave tape. This rolled kit can
then be sterilized and stored, ready for use (Figure 9-41).
When treatment is to begin, the towel kit is unrolled
on the working surface and the instruments arranged
on the sterile surface according to their frequency of
use. The following instruments are contained in the
towel kit:
Three dappen dishes
One Luer syringe, 3 mL (disposable)
One Luer type 27-gauge ProRinse needle
One mouth mirror, Front Surface
Two cotton pliers
One DE spoon excavator, Starlite #31
One plastic instrument, Glick #1, Star Dental
One measuring gauge or millimeter ruler (metal)
One pair of scissors, embroidery, 3
1
4-inch overall
length
One D-G explorer, Star Dental
380 Endodontics
Three gauze sponges, 2 inch
Three cotton rolls #3, 1-inch long
In any number of receptacles, ranging from a simple
bankers sponge soaked in germicide to sophisticated
stainless and plastic holders, the assistant may arrange
the root canal instruments in numerical order and
properly measured to length. It is impractical, if not
impossible, to pass the short-handled instruments to
the operator: hence the orderly arrangement for easy
acquisition. For dentists working alone, the Endoring
(Jordco/Almore International Inc., USA) is recom-
mended (Figure 9-42).
Handpieces
The only regular dental equipment needed, other than
anesthetic syringes and rubber dam equipment, are the
two contra-angle handpieces: one high speed, the other
conventional speed. All handpieces must be sterilized.
The assistant should then place the correct burs in the
contra angles, sized according to the tooth to be treated.
The burs, stored in the sterile instrument case, are
removed from the case with the sterile cotton pliers and
placed in the contra angle with the pliers (Figure 9-43).
While the shaft of the bur is held with the pliers, the
foot control of the conventional handpiece is just
tapped. As the bur spins, it will drop down into place,
and the latch may be closed.
For the high-speed handpiece, the burs can be
dropped down into the chuck, which is then tightened.
The handpiece must be absolutely concentric.
Whipping of the end of the bur, experienced with a
worn chuck, will fracture teeth and is particularly dan-
Figure 9-41 Sterilized towel kit or pack that contains standard
dental instruments necessary for endodontic treatment. Colored
towels are used to identify special endodontic instrument pack,
which has been sterilized and conveniently stored for future use.
Figure 9-40 Orascopic view of the apical foramen and canal walls
taken with a 0.7 mm exible probe that contains 10,000 visual
bers plus light bers (Courtesy of J. K. Bahcall and J. T. Barss.)
Preparation for Endodontic Treatment 381
gerous when an extra long bur is being used to ampu-
tate an entire root.
Endodontic Instrument Case
The collection of tiny endodontic instruments must be
kept in an organized arrangement yet lend itself readi-
ly to sterilization. The metal endodontic instrument
case meets these requirements. Storage cases have long
been available but never as rened as the modern cases
(Figure 9-44). All of the reamers, les, broaches, burs,
and lling equipment, as well as paper points and cot-
ton pellets, are stored and sterilized in the case. The
dentist or assistant removes these with sterile pliers
only as needed.
The instrument case may be placed beside the den-
tist on a Mayo stand, or the assistant may obtain
material from the case kept on the cabinet top.
Supplies are transferred from the case to the open
towel kit, which is the working surface. The case needs
to be resterilized only when one of the instrument
sizes is depleted. New instruments should replace
sizes 10 through 25, which should be used only once.
The larger instruments may be thoroughly cleaned
and reused when the case is replenished before steril-
ization. A thorough discussion of endodontic instru-
ments is found in chapter 10.
A selection of instruments is available from the var-
ious distributors of endodontic supplies. These selec-
tions have been developed for the clinician who treats
all types of endodontic problems in a general practice
of dentistry. The case and its contents are sterilized
according to the directions given under Asepsis in
Endodontic Practice, chapter 3. The surgical arma-
mentarium is dealt with in Endodontic Surgery,
chapter 12. Table 9-1 lists the contents of the endodon-
tic instrument case.
PAIN CONTROL IN ENDODONTICS
In no other area of dentistry is the management of pain
of greater importance than in endodontics. All too
often the patient in need of endodontic therapy has
endured a prolonged period of ever-increasing discom-
fort before seeking dental care. The reasons for this dis-
comfort are manifold; however, there is one simple
explanation in the overwhelming majority of these
patients: They are scared! They are afraid of dentistry,
which might be the reason for their dental problems in
the rst place; they are frightened of root canal work
because of the common perception that it hurts; and
they are often terried at the thought of receiving local
anesthetics, or shots, in patient parlance.
It is possible to achieve clinically effective pulpal
anesthesia on all teeth, infected or not, in any area of
the oral cavity, with a very high degree of success and
without inicting any additional pain on the patient in
the process.
Figure 9-42 Handy Endoring worn by dentist working alone.
Premeasured instruments are arranged in order in sterile, dispos-
able plastic sponge. (Courtesy of Jordco, Inc.)
Figure 9-43 Sterile burs are placed in contra-angle handpiece
with sterile pliers. Bur is dropped into place by holding shaft of
bur with pliers and spinning foot control.
382 Endodontics
Figure 9-44 Five examples of instrument kits. A, ENDO-BLOC. B, University Case. C, ENDEX Endodontic System. D, Guldener
SPLIT-KIT. E, TEXAS Case. (A, Courtesy of Endobloc, Inc., Cincinnati, OH; B, Courtesy of Union Broach, New York; C, Courtesy of
Whaledent International, New York; D, Courtesy of Dentsply/Maillefer; E, Courtesy of University of Texas, San Antonio, TX.)
A
B
D
C
E
Preparation for Endodontic Treatment 383
In the following section, common (and some
uncommon) local anesthesia techniques that are used
to provide effective pain control during dental treat-
ment are presented.
Although it is possible (and probable) that the
administration of local anesthesia will be both atrau-
matic to the patient and clinically effective, many
endodontic patients (and, unfortunately, some profes-
sional colleagues) do not share that feeling. Given that
a signicant percentage of these patients are dental
phobics, and that one of the greatest fears they harbor
is the fear of pain, it is not unusual for these patients to
experience pain at any and all times during treat-
ment, warranted or not. There are the patients who
jump when air is blown into the mouth; who exhibit an
overactive gag reex when anything is placed on the
tongue or palate; who are moving targets during
administration of the local anesthetic; who complain of
pain constantly during treatment, even when the
treatment being performed is truly incapable of pro-
voking a true pain response (eg, cutting enamel or
removal of an existing restoration).
The pain reaction threshold (PRT), dened as that
point at which a person will interpret a stimulus as
being painful, can be altered signicantly in a given
patient. These alterations can be to the patients benet
(elevation of the PRT) or disadvantage (lowering of the
PRT). Given that there is signicant variation in indi-
vidual response to stimulation (as described by the
normal distribution curve), approximately 70% of a
given population will respond appropriately to a given
stimulus (eg, may say ow when receiving a mild
painful stimulus). An additional 15% will under-react
to the same stimulus. Their interpretation of this mild-
ly painful stimulus will be that it did not hurt at all.
This 15% of the population is called hypo-respon-
ders. Thus, approximately 85% of a normal popula-
tion will respond as expected to mildly painful stimuli.
It is the remaining 15% of patients who are the hyper-
responders. Hyper-responding persons will interpret
as painful what are usually nonpainful stimuli. And
then there are the truly remarkable personsthe
Indian fakir who is capable of walking across hot coals
or lying on a bed of nails without experiencing any
pain, or the stoic dental patient who withstands excru-
ciating pain during every aspect of treatment.
With endodontic therapy, the number of patients
who will hyper-respond to stimulation is signicantly
increased. Factors that lower the pain reaction include
(1) the presence of pain at the start of treatment, (2)
fatigue, and (3) fear and anxiety. To varying degrees, all
may be present in endodontic patients.
To increase the likelihood of pain-free endodontic
treatment and to ensure the patient a comfortable
experience, every dentist should make an effort to
modify any of the factors acting to lower the PRT.
Chapter 18 covers a subject of great importance to
the endodontist (analgesics), but also of importance to
the endodontic patient is the matter of sedation. Fear
and pain are a potent combination, capable of provok-
ing some of the most catastrophic situations in the den-
tal office, such as cardiac arrest. In surveying the inci-
Table 9-1 Contents of the Endodontic Instrument
Case
Style B Hand Instruments .02.04 Tapers*
1 6 le, B, #08 1 6 le, B, #50
1 6 le, B, #10 1 6 le, B, #55
1 6 le, B, #15 1 6 le, B, #60
1 6 le, B, #20 1 6 le, B, #70
1 6 le, B, #25 1 6 le, B, #80
1 6 le, B, #30 1 6 le, B, #90
1 6 le, B, #35 1 6 le, B, #100
1 6 le, B, #40 1 6 le, B, #120
1 6 le, B, #45 1 6 le, B, #140
1 6 le, B, Golden Mediums, # 1237
1 12 les Hedstrom, assorted # 25110
Burs
1 3 bur, carbide #701U, RA
1 6 bur, #2 (3 surgical, 3 standard, RA)
1 6 bur, #4 (3 surgical, 3 standard, RA)
1 6 bur, #6 (3 surgical, 3 standard, RA)
Broaches
1 6 barbed broaches, ne
1 6 barbed broaches, medium
1 6 barbed broaches, coarse
1 6 barbed broaches, extra coarse
Obturation Instruments
2 only cement spatula, #3
2 only glass mixing slab, opal
Paper points: ne, medium, and coarse
Cotton pellets: large and small
Special Towel Kits
6 only: double-ended, hand style, M-spreader/pluggers
8 only: Schilder pluggers,
812 Cold sterilized or presterilized gutta-percha points
and cones, assorted sizes (Dentsply/Tulsa, USA)
*The same selection can be made for engine-driven nickel-titani-
um (NITI) instruments, sizes 1580. Both stainless and NITI
les have color-coded handles.
dence of medical emergencies in the dental environ-
ment, Malamed found that 54.9% occurred during the
administration of the local anesthetic and an additional
22.0% occurring during dental treatment.
54
When the
medical emergency arose during treatment, 65.8% of
the occasions were either the extirpation of the pulp
(38.9%) or extraction of a tooth (26.9%). The acute
precipitating cause of the medical emergency was inad-
equate pain control. Although the patient had received
the local anesthetic and had experienced subjective
symptoms of anesthesia (eg, numb lip and tongue), as
the extraction proceeded, or as the preparation came
closer to the pulpal oor, sudden, unexpected pain
occurred. The sudden elevation in blood catecholamine
(epinephrine and norepinephrine) levels provoked sig-
nicant elevations in both the blood pressure and heart
rate and an exacerbation of the patients underlying
medical problems. This resulted in seizures, acute
episodes of angina pectoris or asthma, cerebrovascular
accident (stroke), syncope (fainting), hyperventila-
tion, and psychiatric convergence reactions.
Management problems occurring during local anes-
thetic administration can be almost entirely prevented
if consideration is given by the doctor to the patients
feelings about receiving shots. Most persons do not
relish the thought of receiving intraoral local anesthet-
ic injections, demonstrated by the high incidence of
adverse reactions occurring at this time. Interestingly,
53.9% of all emergencies reported by Malamed were
fainting, and over 54% of all emergencies occurred
during the administration of the local anesthetic.
Syncope during injection can be prevented virtually
100% of the time by following a few simple steps to
make all local anesthetic injections as comfortable
(atraumatic) as is possible (Table 9-2). Although all of
the steps are important, three stand out: (1) placement
of the patient who is to receive an intraoral local anes-
thetic into the supine position before the injection, (2)
the slow administration of the local anesthetic solu-
tion, and (3) the use of conscious sedation before the
administration of the local anesthetic.
The very simple concept behind the successful use of
conscious sedation is that fearful patients are overly
focused on everything that happens to them in the den-
tal chair. Simply by administering a drug (central nerv-
ous system depressant) that takes the patients aware-
ness away from the dental milieu, the patient no longer
over-responds to stimulation, does not care about the
procedure, and in effect becomes a normal patient.
The administration of inhalation sedation with
nitrous oxide and oxygen (N
2
OO
2
), carefully titrat-
ed, alleviates any fears of injections in the majority of
384 Endodontics
needle-phobic dental patients. Continued administra-
tion of N
2
OO
2
during the endodontic procedure is
entirely appropriate if the patient is at all apprehensive.
In addition to relieving patients anxieties, N
2
O acts to
elevate the PRT, providing a benecial effect through-
out the endodontic procedure. N
2
OO
2
is the safest of
all conscious sedation techniques and, when properly
used, is also one of the most effective.
When inhalation sedation is contraindicated (eg,
patient is a mouth breather, patient has a cold or
upper respiratory infection, or sedation has proved inef-
fective in the past in eliminating the patients fears),
other techniques of conscious sedation should be con-
sidered. These include the administration of central
nervous system-depressant drugs (eg, benzodiazepines)
orally, intramuscularly, intravenously, or intranasally.
The safest and most effective, when used properly, is
intravenous conscious sedation. With the availability of
two benzodiazepines, diazepam (Valium) and midazo-
lam (Versed), administered via titration, it is possible to
eliminate the dental fears of virtually all patients.
Additionally, these drugs provide varying degrees of
Table 9-2 Atraumatic Local Anesthesia Technique
1. Use a sterilized, sharp needle.
2. Check the ow of local anesthetic solution before
insertion of needle into tissues.
3. Determine whether to warm the anesthetic cartridge
and/or syringe.
4. Position the patient (supine recommended).
5. Dry the tissue.
6. Apply topical antiseptic (optional).
7a. Apply topical anesthetic (minimum 12 minutes).
7b. Communicate with the patient.
8. Establish a rm hand rest.
9. Make the tissue taut.
10. Keep syringe out of the patients line of sight.
11a. Insert needle into the mucosa.
11b. Watch and communicate with the patient.
12. Slowly advance the needle toward target.
13. Deposit several drops of local anesthetic before
touching periosteum.
14. Aspirate.
15a. Slowly deposit local anesthetic solution.
15b. Communicate with the patient.
16. Slowly withdraw syringe. Make needle safe and
discard.
17. Observe patient after injection.
18. Record injection on the patients chart.
Adapted from Malamed SF.
57
Preparation for Endodontic Treatment 385
amnesia, the patient having no recall of events occur-
ring during their treatment (it didnt happen).
Because of the prevalence of fear in endodontic
patients, the use of conscious sedation should become
increasingly more popular. Unfortunately, the use of
conscious sedation by endodontists is extremely rare.
The benets to be gained from the proper use of con-
scious sedation greatly outweigh the very slight risks
involved with their use.
Local Anesthetic Techniques
Problems arising in achieving profound pulpal anesthe-
sia invariably develop in the mandible (Table 9-3). A
survey by Walton and Abbott of 120 missed local anes-
thetic injections demonstrated that maxillary teeth were
the problem 32% of the time.
55
On the other hand, on
two of three occasions when anesthesia was ineffective,
mandibular teeth were involved. Mandibular molars
were the culprit 47% of the time. Repeating the same
survey, Malamed found signicantly different results.
56
When inadequate local anesthesia developed, maxillary
teeth were the problem only 9% of the time, whereas
91% of the offending teeth were in the mandible. Of
even greater signicance is the fact that mandibular
teeth, other than molars, were never the problem (0%).
Why the relative lack of anesthesia problems in the
maxilla compared with the mandible? The very differ-
ent composition of the cortical plate of bone on the
buccal aspect of maxillary and mandibular teeth is one
factor. In the adult mandible, the buccal cortical plate
of bone is signicantly thicker than that found overly-
ing maxillary teeth. This added thickness makes the use
of supraperiosteal anesthesia ineffective in the
mandible, obviating the use of the easiest and most
effective injectioninltration.
Mandibular Anesthesia
To provide effective pulpal anesthesia in the mandible,
one must administer the local anesthetic drug at a site
where the nerve is still accessible (eg, before the nerve
enters the mandibular foramen and into the mandibu-
lar canal). Thus, one is limited to two injection sites.
One site is the lingual aspect of the mandibular ramus,
where three techniques may be used: the inferior alve-
olar (IA) nerve block (the traditional mandibular
block); the Gow-Gates mandibular nerve block
(GGMNB), and the Akinosi-Vazirani closed-mouth
mandibular nerve block. A second site of access to the
mandibular nerve is available on the mandible, the
mental foramen, located (usually) between the two
premolars. Local anesthetic administered at this site
will provide profound pulpal anesthesia of the premo-
lar, canine and incisor teeth virtually 100% of the time,
even when infection is present.
On those occasions when these three mandibular
nerve block injections fail to provide successful pulpal
anesthesia, one of several supplemental techniques may
be considered. These include the periodontal ligament
(PDL) injection, intraosseous (IO) anesthesia, and
intrapulpal injection. The IO technique has proved to
be of tremendous benet in endodontics, particularly
as a means of providing anesthesia to the hot
mandibular molar.
Maxillary Anesthesia
Although profound anesthesia of maxillary teeth is
normally easier to obtain, problems, if they occur, usu-
ally do so following the administration of an inltra-
tion injection to a central incisor, canine, or molar. The
apex of the central incisor may lie under the cartilage of
the nose, making inltration less effective (as well as
more uncomfortable). Canines that have longer than
usual roots may not be anesthetized when the anes-
thetic is deposited below the apex (needle is not insert-
ed far enough). Inltration anesthesia of maxillary
molars will fail in situations where the palatal root
ares greatly toward the midline of the palate. Most
local anesthetics inltrated into the buccal fold will not
diffuse far enough toward the midline to provide ade-
quate pulpal anesthesia in this situation. Additionally,
where periapical infection is present, the success rate of
injected local anesthetics is diminished, sometimes
considerably.
Fortunately, maxillary anesthesia can readily be
achieved through the administration of nerve blocks.
Three nerve blocks, the posterior superior alveolar
(PSA), middle superior alveolar (MSA), and anterior
superior alveolar (ASA, infraorbital), successfully
provide pulpal anesthesia to maxillary teeth, even in
the presence of infection.
Mandibular Techniques
The techniques are described briey and their advan-
tages and disadvantages highlighted. For a more in-
Table 9-3 Teeth Requiring Supplemental Injections
Maxillary: Maxillary: Mandible: Mandible:
Teeth Walton Malamed Walton Malamed
Anteriors 2% 2% 9% 0%
Premolars 18% 2% 12% 0%
Molars 12% 5% 47% 91%
Adapted from Walton RE and Abbott BJ
55;
Malamed SF.
56
depth description of these techniques, the reader is
referred to local anesthesia textbooks by Malamed
57
and Jastak and Yagiela.
58
Inferior Alveolar Nerve Block (IANB) (Table 9-4).
This traditional mandibular nerve block provides,
when successful, pulpal anesthesia of all mandibular
teeth in the quadrant, along with buccal soft tissues and
bone anterior to the mental foramen and the lingual
soft tissues and anterior two-thirds of the tongue.
Many approaches exist to this technique, all of which
are acceptable, with two provisos: (1) the success rate
for pulpal anesthesia should be at least 85% (with one
injection depositing approximately 1.5 mL of anesthet-
ic), and (2) the technique should not increase risk of
harm to the patient.
The aim in the classic Halstad approach to the IANB
is to deposit local anesthetic at the mandibular fora-
men, the site where the IA nerve enters the mandibular
canal. Although still taught as the primary mandibular
technique in most dental schools, the 85% success rate
for pulpal anesthesia encountered with this technique
is the lowest of any injection administered in dentistry.
The most common reason the IANB is missed is caused
by depositing the anesthetic solution below the
mandibular foramen. As the IA nerve has already
entered into the thick bony canal, pulpal anesthesia is
not produced. The experienced doctor will re-adminis-
ter additional local anesthetic at the site slightly
(5 mm) higher than the initial site. The patient should
be in a supine position during the IANB, but it is rec-
ommended that they be returned to a more upright
(comfortable) position following drug administration
and while awaiting the onset of anesthesia.
Gow-Gates Mandibular Nerve Block
5961
(Table 9-5).
The GGMNB is a true third division (V
3
) nerve block,
providing pulpal anesthesia to all mandibular teeth in
the quadrant, as well as the same soft tissue distribution
386 Endodontics
as the IANB. Additionally, the GGMNB provides senso-
ry anesthesia of the buccal nerve as well as the mylohy-
oid nerve, eliminating one cause of partial anesthesia
seen in mandibular rst molars in approximately 1% of
patients.
Local anesthetic is deposited on the lateral aspect of
the neck of the mandibular condyle (Figure 9-45). V
3
has
just exited the foramen ovale and, with the patients
mouth maintained in a wide-open position, the nerve
lies near the condylar neck. First discussed in 1973, the
GGMNB has slowly become more and more popular.
Once learned, the GGMNB will provide a greater success
rate for mandibular pulpal anesthesia.
61
Unfortunately, a
learning curve does exist, and some doctors, frustrated
by early failures, abandon this excellent technique. The
major problem encountered in learning the GGMNB is
the inability to contact bone at the neck of the mandibu-
lar condyle. The primary reason for this failure is closure
(even slight closure) of the patients mouth while the
needle is being advanced (Figure 9-46).
Table 9-4 Inferior Alveolar Nerve Block
Teeth Anesthetized Recommended Needle Volume of Anesthetic + Aspiration VAS*
All mandibular teeth in quadrant 25 gauge: long 1.5 mL 1015% 14
*VAS = visual analog scale, a rating of pain sensation. A score of 0: felt nothing; 1: minor, no problem; 3: some discomfort; 10:
worst pain ever experienced.
Table 9-5 Gow-Gates Mandibular Nerve Block
Teeth Anesthetized Recommended Needle Volume of Anesthetic + Aspiration VAS
All mandibular teeth in quadrant 25 gauge: long 1.83.0 mL 12% 13
VAS = visual analog scale.
Figure 9-45 Gow-Gates mandibular block injection needle at the
target area, the lateral aspect of the neck of the condyle. (Courtesy
of Drs. Colin and Gwenet Lambert.)
Preparation for Endodontic Treatment 387
As with the IANB, patients receiving the GGMNB
should be supine during the injection, but returned to
a more upright, comfortable position at the conclusion
of the injection and while awaiting the onset of anes-
thesia. It is important that the mouth be maintained in
a wide-open position throughout the injection and for
2 minutes following its completion.
Akinosi-Vazirani Mandibular Nerve Block (Closed-
Mouth Technique)
62,63
(Table 9-6). Described in 1977,
this mandibular block technique is of benet in situa-
tions in which unilateral trismus is present, secondary to
repeated mandibular injections at a previous dental visit.
The patient is unable to open the mouth more than a few
millimeters, preventing the administration of intraoral
local anesthesia, as well as the performance of dental
treatment. Since V
3
is both a sensory and motor nerve
(to the muscles of mastication), blockade of V
3
provides
relief of the muscle spasm, permitting the patients
mouth to open and the planned dental care to proceed.
The teeth are kept lightly in contact throughout the
injection and the cheek is retracted. A long needle,
either a 25- or a 27-gauge is placed, with its bevel fac-
ing the midline, into the buccal fold on the side of
injection at the height of the mucogingival junction of
the last maxillary molar (this injection is intermediate
in height between the GGMNB and IANB). Soft tissue
on the lingual aspect of the mandible is penetrated at a
site immediately adjacent to the maxillary tuberosity
and the needle is advanced 25 mm, where the local
anesthetic is deposited. Motor paralysis usually devel-
ops before soft tissue and pulpal anesthesia. The
patient, supine during the injection, should be reposi-
tioned more upright (comfortable) following injection
and while awaiting onset of anesthesia.
Incisive Nerve Block (INB) (Mental NB) (Table 9-7).
The INB is an underused technique, but one that pro-
vides pulpal anesthesia to the ve mandibular anterior
teeth on a very reliable basis, even in the presence of
infection. Soft tissue anesthesia of the lower lip, skin of
the chin, and buccal soft tissues anterior to the mental
foramen is achieved 100% of the time. Local anesthesia
is inltrated outside the mental foramen and then, with
the use of nger pressure, forced into the foramen and
mandibular canal where the incisive nerve (a terminal
Figure 9-46 Gow-Gates injection technique. A, Patient is supine,
mouth opened widely and head extended. Syringe is aligned with a
plane from the intertragic notch on the ear and the opposite corner of
the mouth. B, Laterally the syringe is aligned with are of the tragus of
the ear to the face and usually lies over the mandibular canine or pre-
molars on opposite side. (Courtesy of Drs. Colin and Gwenet Lambert.)
A
B
Table 9-6 Akinosi-Vazirani Mandibular Nerve Block (Closed-Mouth Technique)
Volume of Anesthetic
Teeth Anesthetized Recommended Needle (Adult) + Aspiration VAS
All mandibular teeth in quadrant 25 or 27 gauge: long 1.8 mL < 10% 02
VAS = visual analog scale.
branch of the IA nerve) is located. Pressure should be
applied to the area for at least 1 minute, preferably 2
minutes, following deposition of the anesthetic. Lingual
soft tissues, including the tongue, are not anesthetized
in the incisive nerve block. Should lingual soft tissue
anesthesia be required for placement of a rubber dam
clamp, it can be achieved painlessly by advancing the
needle through the already anesthetized buccal papilla
toward the lingual while depositing small volumes of
local anesthetic en route. With proper technique (eg,
nger pressure for 2 minutes), the INB is virtually 100%
successful, painless (there is no need for the needle to
contact bone), and can be used successfully from the
outset (there is no learning curve for this injection).
Maxillary Techniques
Posterior Superior Alveolar Nerve Block (PSANB)
(Zygomatic NB) (Table 9-8). When successful pul-
pal anesthesia of maxillary teeth is not achieved
through supraperiosteal injection, nerve block anesthe-
sia usually succeeds. PSANB provides consistently reli-
able pulpal anesthesia to the three maxillary molars,
even in the presence of infection or widely ared
palatal roots. Buccal soft tissues and bone overlying this
area are also anesthetized. As no bone is contacted in
PSANB, the injection is extremely comfortable; howev-
er, the absence of bony contact increases the risk of
developing a hematoma following the injection. This
usually develops when the needle is advanced too far
into the tissues. From the needle penetration site in the
buccal fold by the second maxillary molar, the short
needle is advanced to a depth of 16 mm in an inward,
upward, and backward direction. This places the needle
tip into the pterygomaxillary space, where the PSA
388 Endodontics
nerves are located. In some patients, the mesiobuccal
(MB) root of the rst molar may not be anesthetized
with the PSANB but may be anesthetized by an MSA
nerve block, described in the following paragraph.
64
Middle Superior Alveolar Nerve Block (MSANB)
(Table 9-9). When present, the MSA nerve provides
pulpal anesthesia to the two premolars and the MB
root of the rst molar (as well as the buccal soft tissues
and bone overlying this area). Advancing the tip of the
needle well above the apex of the second premolar and
administering 0.9 mL of anesthetic will provide suc-
cessful anesthesia almost 100% of the time.
Anterior Superior Alveolar Nerve Block (ASANB)
(Infraorbital NB) (Table 9-10). In a technique
technically similar to the incisive nerve block (men-
tal) in the mandible, the ASANB provides pulpal anes-
thesia to the incisors, canine, and both premolars on
the side of injection, as well as their overlying soft tis-
sues. The ASA is highly successful in the presence of
infection (unless the infection is present in the region
of the infraorbital foramen). The needle is inserted into
the buccal fold by the rst premolar and aimed for the
infraorbital foramen, which is located by palpation. A
volume of 0.9 mL of local anesthetic is deposited out-
side the infraorbital foramen and then forced into the
foramen by the application of nger pressure for 2
minutes (1 minute minimally).
Supplemental Injection Techniques
Periodontal Ligament (PDL) Injection and Intraliga-
mentary Injection (ILI)
6567
(Table 9-11). When pul-
pal anesthesia of a single tooth is required, the PDL injec-
tion should be considered. This is of special importance
in the mandible, where nerve block anesthesia is the
Table 9-8 Posterior Superior Alveolar Nerve Block
Volume of Anesthetic
Teeth Anesthetized Recommended Needle (Adult) + Aspiration VAS
Maxillary molars 25 or 27 gauge: short 0.9 mL 3.1% 02
VAS = visual analog scale.
Table 9-7 Incisive Nerve Block
Volume of Anesthetic
Teeth Anesthetized Recommended Needle (Adult) + Aspiration VAS
Mandibular incisors and canine 27 gauge: long 0.6 mL 5.7% 02
and premolars
VAS = visual analog scale.
Preparation for Endodontic Treatment 389
norm. In the maxilla, supraperiosteal injection inltrated
above the apex of any tooth will provide successful pulpal
anesthesia with a success rate of > 95%. Because of the
thickness of the mandibular cortical plate of bone (in
adults), inltration techniques are doomed to failure.
Therefore, although the PDL may be successfully admin-
istered to any tooth, its use is most often reserved for
mandibular teeth, specically mandibular molars.
Although special syringes have been developed to
assist in delivery of the local anesthetic in the PDL
injection, a regular syringe may be used quite effective-
ly. A volume of 0.2 mL of local anesthetic solution must
be deposited interproximally on each root of the tooth
to be treated. The bevel of the needle should be placed
against the root of the tooth while it is advanced down
into the PDL space until resistance prevents any further
penetration (Figure 9-47 and Figure 9-48). As the anes-
thetic is slowly deposited, it should be noted that there
is signicant resistance to the administration of the
solution and that the soft tissues in the area become
ischemic. Presence of these two signs usually connotes
successful anesthesia. Onset of clinical action is imme-
diate; however, the duration of pulpal anesthesia is
quite variable, although it is most often long enough to
permit access to the pulp chamber of a previously sen-
sitive tooth.
Two contraindications exist to administration of the
PDL injection: primary teeth and the presence of peri-
odontal infection. The presence of pocket infection in
the site of needle insertion increases the risk of
osteomyelitis developing subsequent to the injection
(Figure 9-49).
Intraosseous (IO) Anesthesia
6871
(Table 9-12). In
true IO anesthesia, local anesthetic is injected directly
into the bone surrounding the root of a tooth.
Conceptually the IO injection is quite simple: the
impediment to local anesthetic diffusion through bone
in the adult mandible is the thickness of the cortical
plate. Where a foramen is present, such as the mental
foramen, the drug can gain access to the nerve and pro-
duce conduction blockade. Unfortunately, no such
foramen is found on the buccal aspect of the mandible
distal to the mental foramen, making it more difficult
to obtain consistently reliable pulpal anesthesia on
mandibular molars (see Table 9-3).
In the IO technique, a small perforation or foramen
is made through the cortical plate of bone with a tiny
dental bur, into which a needle is inserted and local
Table 9-10 Anterior Superior Alveolar Nerve Block
Volume of Anesthetic
Teeth Anesthetized Recommended Needle (Adult) + Aspiration VAS
Maxillary incisors, canine premolars 25 gauge: long 0.9 mL 0.7% 02
+ MB root rst molar
MB = mesiobuccal; VAS = visual analog scale.
Table 9-9 Middle Superior Alveolar Nerve Block
Volume of Anesthetic
Teeth Anesthetized Recommended Needle (Adult) + Aspiration VAS
Maxillary premolars 27 gauge: short 0.9 mL < 3% 02
+ MB root rst molar
MB = mesiobuccal; VAS = visual analog scale.
Table 9-11 Periodontal Ligament Injection and Intraligamentary Injection
Volume of Anesthetic
Teeth Anesthetized Recommended Needle (Adult) + Aspiration VAS
1 tooth 27 gauge: short 0.2 mL per root 0% 010
VAS = visual analog scale.
390 Endodontics
Figure 9-47 Needle penetrating distal periodontal ligament space
of mandibular molar. (Courtesy of Drs. Colin and Gwenet
Lambert.)
Figure 9-48 Insertion of needle for periodontal ligament injec-
tion. a, Correct insertion, bevel faces cribriform plate. b, Incorrect
insertion directing stream toward tooth. (Courtesy of Drs. Colin
and Gwenet Lambert.)
Figure 9-49 Damage and repair to periodontal structures from intraligamental injection. A, Needle tract from lower right into gouged
cementum, top left. Chips of cementum (C), erythrocytes (E), and debris (D) carried in by needle indicate severity at time of injury. B, Tissue
repair 25 days after intraligamental injection. New bone (arrows) has replaced bone resorbed following injection. Reproduced with permis-
sion from Walton RE, Garnick JJ. JOE 1982;8:22.
Preparation for Endodontic Treatment 391
anesthetic is administered. Intraosseous injections can
provide anesthesia of but a single tooth or of multiple
teeth in a quadrant, depending on the site of injection
and the volume of anesthetic administered. When
treating one or two teeth, 0.45 to 0.6 mL is usually used.
IO anesthesia has proved to be of great benet in
endodontics when traditional injection techniques fail.
Nusstein et al. found that 81% of mandibular and 12%
of maxillary teeth in 51 patients diagnosed with irre-
versible pulpitis required IO anesthesia because of fail-
ure to gain pulpal anesthesia with inltration or IA
nerve block. IO anesthesia was found to be 88% suc-
cessful in gaining total pulpal anesthesia for endodon-
tic therapy.
70
Parente et al. administered IO anesthesia to 37
patients with irreversible pulpitis.
71
Thirty-four were
mandibular molars, 2 were maxillary molars, and 1 was
a maxillary anterior tooth. Maxillary teeth received
inltration anesthesia, whereas mandibular teeth
received the IA injection with a minimum of 3.6 mL of
local anesthetic. IO anesthesia successfully provided
pulpal anesthesia in 91% of mandibular molars
(31/34) and for two of three maxillary teeth.
There are two concerns regarding the IO injection.
First, the local anesthetic is administered into a highly
vascular site, where absorption into the cardiovascular
system is quite rapid. Administration of an overly large
volume of local anesthetic could lead to elevated blood
levels of the anesthetic and signs and symptoms of
overdose. The second concern regards the inclusion of
vasopressors (eg, epinephrine) in the local anesthetic
solution. This can lead to a rapid absorption into the
cardiovascular system leading to an epinephrine reac-
tion in which patients experience mild tremors of the
extremities, palpitations, and diaphoresis after receiv-
ing the IO injection. Use of a vasopressor-containing
local anesthetic in a patient with signicant cardiovas-
cular disease could provoke potentially life-threatening
complications. It is recommended that a plain non-
epinephrine local anesthetic solution be used in the IO
technique.
Intrapulpal Anesthesia
72
(Table 9-13). When the
pulp chamber has been exposed and, because of exqui-
site sensitivity, treatment cannot proceed, intrapulpal
anesthesia should be considered. With the increased
interest in the very successful IO technique, however,
the need for intrapulpal anesthesia should diminish.
A small needle is inserted into the pulp chamber
until resistance is encountered (Figure 9-50). The local
anesthetic must be injected under pressure. There will
be a brief moment of intense discomfort as the injec-
tion is started, but anesthesia usually supervenes almost
immediately, and instrumentation can proceed pain-
lessly. Because of the discomfort involved in intrapulpal
anesthesia, the patient must be advised of this before the
injection is begun. The concurrent administration of
inhalation sedation (N
2
OO
2
) or intravenous Versed
will minimize patient response by alleviating the PRT.
Summary
Clinically effective pain control can be achieved in the
vast majority of patients requiring endodontic therapy.
When problems achieving pain control occur, it is usu-
ally at the initial visit, when a frightened patient, who
has been hurting for some period of time, nally seeks
relief from pain yet oftentimes is unable to manage the
fears of dentistry. Through a combination of thought-
ful caring for the patient, the use of conscious sedation,
when indicated, and the effective administration of
local anesthesia, endodontic treatment can proceed in
Table 9-13 Intrapulpal Injection
Volume of Anesthetic
Teeth Anesthetized Recommended Needle (Adult) + Aspiration VAS
1 tooth 27 gauge: short 0.2 to 0.3 mL 0% 510
VAS = visual analog scale.
Table 9-12 Intraosseous Anesthesia
Volume of Anesthetic
Teeth Anesthetized Recommended Needle (Adult) + Aspiration VAS
1 or 2 teeth 27 gauge: short 0.45 to 0.6 mL 0% 02
VAS = visual analog scale.
a more relaxed and pleasant environment for both the
patient and dental staff.
ENDODONTIC PRETREATMENT
Root canal therapy does not necessarily begin with the
placement of the rubber dam but with the restorative
or periodontic procedures necessary to simplify its
placement. These procedures determine the restorabil-
ity of the tooth and establish a healthy periodontal rela-
tionship between tooth, gingiva, and bone.
Pretreatment encompasses all procedures that ensure
the ease of root canal treatment directed toward restor-
ing and maintaining the involved tooth. The type of
pretreatment varies with each case, but certain funda-
mental objectives must be considered:
1. Prevention of postoperative discomfort and the
inopportune fracture of teeth. Gross occlusal reduc-
tion should be performed on any decayed or lled
posterior tooth undergoing root canal therapy. All
such teeth will be required to have capped cusp
restorations or full crowns on completion of treat-
ment. This reduction should be done before rubber
dam placement to check occlusal clearance in all
excursive movements. It should also be done before
the rst endodontic treatment, rather than after, in
order not to disturb cuspal reference points used to
establish proper length of the tooth. Exempt from
this pretreatment are posterior teeth that have been
adequately restored and anterior teeth.
392 Endodontics
2. Prevention of bacterial contamination from salivary
leakage and prevention of percolation of intracanal
medication. All faulty restorations and carious defects
must be removed and replaced with temporary lling
material(TERM) (L. D. Caulk; Milford, Dela.) or with
alloy in the case of two or three surface llings.
To restore a minimal defect on the proximal,
TERM can be placed after the endodontic appoint-
ment is completed and before the removal of the
rubber dam.
73
On subsequent appointments, nor-
mal access can be made through the TERM tempo-
rary, but if such access weakens the lling, the entire
temporary should be replaced at each visit.
The use of Cavit (Premier-Espe; Norristown, Pa.)
is limited by its slow-setting property, requiring 1
hour in a wet environment to reach a complete set.
74
It is also inadequate in large two- and three-surface
temporary restorations and will never last beyond a
week in any case.
75
Pretreatment often requires that a tooth be built
up with temporary cement before the placement of
the rubber dam. For example, a carious defect may
extend subgingivally, permitting salivary leakage
from beneath the rubber dam. In this situation, a
fast, hard-setting lling, such as TERM or Ketac-Fil
cement (Espe, USA), or alloy will permit the imme-
diate placement of the rubber dam clamp and will
withstand repeated application of the clamp.
3. Provision of a sound margin of tooth structure for
rubber dam placement. The sound margin may be
exposed by periodontal procedures or the crown
may be restored with a temporary band.
Periodontal Therapy
Gingival hyperplasia or hypertrophy can be easily
removed by gingivectomy or by the use of electro-
surgery or laser. Both techniques are expedient but
have the disadvantage in some cases of producing large
surface wounds that may hemorrhage and must heal by
secondary intention.
In such situations, and in cases in which the crown
has been fractured or destroyed to the gingival level, a
more rened mucogingival technique is indicated. The
inamed gingival margin is removed by means of an
internally beveled horizontal incision. This measure
eliminates an external wound and permits a rubber
dam application immediately on completion of the
procedure without the problem of hemorrhage con-
trol. Two vertical relaxing incisions, extended from the
gingival margin into the alveolar mucosa, create a
mucogingival ap and permit the free movement of
this ap to be repositioned apically and sutured to
Figure 9-50 Intrapulpal pressure anesthesia with lidocaine. A,
Coronal injection through pinhole opening in dentin. B, Pulp canal
injection for each individual canal. Needle is inserted tightly and
one drop of solution is deposited. (Courtesy of Drs. Colin and
Gwenet Lambert.)
A B
Preparation for Endodontic Treatment 393
place. This technique permits the exposure of addition-
al root surface for the placement of the rubber dam
clamp and nal restoration. In some cases, corrective
osseous recontouring may be necessary (Figure 9-51).
Copper Bands
The preceding periodontal procedures are expedient
and can usually be limited to the endodontically
involved tooth. However, there are some problems that
cannot be easily corrected by periodontal therapy.
Gross subgingival caries may be better treated by the
cementation of a copper band custom tted to the par-
ticular carious defect (Figure 9-52). The extraction of a
partially erupted third molar may leave a bony defect
and a deep carious lesion on the distal root of the sec-
ond molar (Figure 9-53). A copper band may be readi-
ly adapted to extend subgingivally in this area, where
anatomic considerations preclude denitive periodon-
Figure 9-51 A, Preoperative view of maxillary canine whose crown is totally destroyed by caries under defective bridge abutment. Level of
gingival tissue (arrow) in relation to remaining root is apparent. B, View following root canal therapy and apical repositioning of attached
gingiva. Elongation of clinical crown is seen (arrow) in comparison with view in A. C, View of nal restoration. Important canine abutment
(arrow) is salvaged by combined endodonticperiodontic procedures. (Restoration by Dr. James Haberman.) D, Retrolling of pulpless
canine abutment was done during mucogingival surgery. Previous endodontic lling was incomplete. (Endodonticperiodontic therapy by
Dr. Edward E. Beveridge.)
A B
D
C
tal therapy. In severe cases, the periodontal or carious
defect may be beyond repair, requiring hemisection of
the distal root of the lower second molar. Banding may
then be helpful to seal off the bisected pulp chamber.
Orthodontic Bands
Whereas the copper band is custom-tted to adapt to a
carious defect extending well below the gingival mar-
gin, the orthodontic band is prefabricated to t the
tooth supragingivally. Thus, it is not used to replace the
copper band but to help retain a large temporary lling
or support a tooth with undermined enamel walls. It is
an essential step in the treatment of a tooth that is
thought to be cracking or split (Figure 9-54). It serves
as an excellent temporary restoration to prevent split-
ting during extended treatment, or after treatment,
when nal restoration has to be postponed. All bands
are cemented with zinc oxyphosphate cement.
Temporary Crowns and Restorations
Aluminum shell crowns and plastic crowns or bridges
cemented with zinc oxideeugenol cement are not
acceptable as proper pretreatment temporization. The
placement of the rubber dam clamp and the tension of
the rubber dam displace these temporary crowns, as
does repeated rubber dam application and endodontic
manipulation. In addition, access attempted through
the temporary crown and cement may easily be misdi-
rected against one of the axial walls of the preparation
instead of directly into the pulp chamber.
RUBBER DAM APPLICATION
Rubber dam application is an essential prerequisite for
providing nonsurgical endodontic treatment. For root
canal treatment, rapid, simple, and effective methods of
394 Endodontics
dam applications have been developed. In all but the
most unusual circumstances, the rubber dam can be
placed in less than 1 minute.
Although the modern endodontic approach to the
use of the dam has changed, the importance and pur-
poses of the dam remain the same:
1. It provides a dry, clean, and disinfected eld.
2. It protects the patient from the possible aspiration
or swallowing of tooth and lling debris, bacteria,
necrotic pulp remnants, and instruments or operat-
ing materials
7678
(Figure 9-55).
3. It protects the patient from rotary and hand instru-
ments, drugs, irrigating solutions, and the trauma of
repeated manual manipulation of the oral soft tissues.
Figure 9-52 A, Badly broken-down pulpless molar with root resorption. Before endodontic treatment, cavity must be sealed off. B,
Custom-tted copper band allows for full treatment. (Courtesy of Dr. James D. Zidell.)
Figure 9-53 Destruction caused by partially erupted third molar
and caries. Extended copper band will isolate crown for endodontic
treatment. (Courtesy of Dr. James D. Zidell.)
Preparation for Endodontic Treatment 395
4. It is faster, more convenient, and less frustrating
than the repeated changing of cotton rolls and/or
saliva ejectors.
The rubber dam also provides a uid seal from saliva
from the working eld. It has been recently shown in vivo
that intraoral and extraoral microorganisms contaminat-
ing the root canal system will lead to eventual failure.
79
Equipment
Time-and-motion studies have stressed the efficacy of
kit or tray preparations that pool instruments and
materials to be used in a given procedure. Applied to
rubber dam application, this system encourages its
more routine use.
Dam Material. Rubber dam is available in a variety
of thicknesses, colors, sizes, methods of packaging, and
material. The medium-weight thickness is recommend-
ed for general all-around use. It has the advantage of
cupping around the cervical of teeth, providing a uid
seal without the use of oss ligature ties around each
tooth. Also, it does not tear or rip easily and provides an
unusual degree of protection from injury for the under-
lying soft tissues. It exerts a greater retracting force on
the lips and cheeks than does the thinner material, thus
affording greater access and improved vision.
There are advantages, however, in using the thin
weight dam on mandibular anterior teeth and partially
erupted posterior teeth. The problem of retaining a
clamp on these tapered teeth, with little or no cervical
undercut, is solved by applying the thinner dam, which
exerts less dislodging force on the clamp. The disad-
vantage is that it is easily torn.
Dam materials may be purchased in 5- or 6-inch-
wide rolls to be cut to size; precut sheets, either 5 inch-
es 5 inches, 5 inches 6 inches, or 6 inches 6 inch-
es unsterilized and boxed; or precut and individually
sterilized and packaged. A sheet 6 inches 6 inches will
ll all needs of various applications and is large enough
to t any size frame.
The choice of light or dark-colored material is large-
ly up to the individual. However, dark material pro-
vides a contrasting color as a background for the light-
colored tooth.
Rubber dam is available in latex and nonlatex materi-
al. The prevalence of allergies to latex has been increas-
ing; it is important to recognize patients who may have
an allergy to latex.
80
Latex-free dams, such as silicone
rubber (Coltene/Whaledent/Hygenic Corporation,
USA], are currently available. Additionally, the digits can
be cut from a vinyl glove, and the remainder can be
adapted to act as a rubber dam in patients who exhibit
hypersensitivity to latex.
Punch. Any rubber dam punch that is convenient
for the operator and creates a sharp clean hole in the
dam material is satisfactory. All too often the punch has
not been correctly centered over a hole, and a nick on
the cutting margin results, producing an incomplete
jagged cut in the dam material. This is easily corrected
by sharpening the cutting edge of the hole with car-
borundum stone. Failure to correct this punching error
will result in salivary leakage and contamination of the
eld at the site of the ragged hole in the dam.
Personnel at the Karolinska Institute were amazed to
learn that [M]icrobiologic leakage between the rubber
dam and the tooth, in routine endodontic treatment,
was found in 53% of the cases that, clinically, appeared
to be free from saliva leakage.
81
They indicted the
time factorthe longer the dam was in place, the
Figure 9-54 Prefabricated orthodontic band for supragingival
containment of large temporary proximal lling or to support
weakened enamel walls. (Courtesy of Dr. James D. Zidell.)
Figure 9-55 Swallowed endodontic le ended up in appendix and
led to acute appendicitis and appendectomy. Rubber dam would
have prevented this tragedy. Reproduced with permission from
Thomsen LC, et al. Gen Dent 1989;37:50.
greater the chance of contamination. Stretching the
dam while taking radiographs and capillary forces also
contributed. Leakage was signicantly reduced by
application of a wound dressing, Nobecutane (Astra
Pharmaceutical, Sweden) and silicone medical adhe-
sives (Dow Corning Medical Products, USA) to seal the
dam and the tooth.
81
Others have sealed this interface with cyanoacry-
late,
82
rubber base adhesive,
83
Super Poli-Grip Denture
Adhesive (Dentico, Inc., USA), and Oraseal (Ultradent
Products, USA), made specically to seal the rubber
dam, including tears in the dam (Figure 9-56).
Frames. In addition to supporting the dam,
frames should be radiolucent to prevent obliteration of
an important area on the endodontic working radi-
ograph. There are a variety of rubber dam frames that
meet these requirements. The U-shaped Youngs frame
is made of either metal for use in restorative dentistry
or of radiolucent plastic for endodontic applications. It
is easily manipulated and is widely used. This frame
holds the dam against the patients face, and an
absorbent napkin under the dam can be used for
patient comfort.
The Nygaard-stby (N-) rubber dam frame
(Coltene/Whaledent/Hygenic Corp.; Mahwah, N.J.) is
shield shaped, made of radiolucent nylon, and may be
in place while a tooth is subjected to x-ray without
interfering with the radiographic image (Figure 9-57).
It tends to hold the dam away from the patients face
and is thus cooler, drier, more comfortable, and
requires no absorbent napkin. Because of its shape, it
also directs the breath from the nostrils away from the
operative eld, thus minimizing possible root canal
contamination by nasal staphylococci* (see Figure 9-
57).
396 Endodontics
Another U-shaped frame, the Starlite VisiFrame
(Interdent Inc.; Culver City, Calif.), is also made in
radiolucent plastic. Because of its shape, it exerts less
tension on the dam and is easier to use than the N
frame when taking radiographs of molars. Like the
N frame, it requires no absorbent napkin, and
stands away from the face.
An innovative, articulated frame developed to facili-
tate endodontic radiography is le Cadre Articul (the
articulated frame) (Jored, Ormoy, France, and Trophy,
USA). Developed in France by Dr. G. Sauveur, it is
curved to t the face (Figure 9-58, A) and is hinged in
the middle to fold back, allowing easier access for radi-
ographic lm placement (Figure 9-58, B).
Clamps. Although a basic selection of ve to seven
clamps will permit most dentists to place a clamp and
dam on a majority of teeth encountered, the more
experienced operator builds up a larger collection over
the years. Teeth that are rotated, partially erupted,
malaligned, fractured, anomalous in crown form, or
with severe carious involvement all present problems
requiring special clamps or clamping techniques.
Table 9-14 lists a suggested assortment of metal
clamps for the various teeth. Incisor and premolar
clamps that are losing their tension should be retained
as they often make excellent clamps for unusual molar
applications.
Figure 9-56 Oraseal ejected from tube seals tear in rubber dam,
despite moisture from saliva. (Courtesy of Ultradent Prod., USA.)
Figure 9-57 N- rubber dam frame, developed in nylon by
Nygaard-stby, is radiolucent and will not impede x-rays. Frame is
curved to t patients face and may be positioned so that patient
breathes behind dam and not into operative eld, as one would with
a Wizard frame. (Courtesy of Coltene/Whaledent/Hygenic Corp.)
*This most important point bears emphasis. All of the dental office
personnel should have nose cultures, and if staphylococci are pres-
ent, should apply Neosporin or Mycitracin to their nostrils each day.
Preparation for Endodontic Treatment 397
Plastic clamps (Moyco/Union Broach, USA) are
also available in two sizes, large and small, and are
used in selected cases. When metal clamp obstruction
is a problem in radiography, radiolucent plastic
clamps allow for an unobstructed view of the tooth.
Plastic clamps can also be used to isolate teeth during
vital tooth bleaching, using a heat lamp to avoid
excessive heat buildup that occurs with conventional
metal clamps.
Metal rubber dam clamps may damage tooth struc-
ture, restorations, and the porcelain surface of crowns
or veneers. Conicting reports have recently been pub-
lished on the effect of rubber dam retainers on the sur-
face of porcelain. One study reported that damage to
the porcelain surface resulted when metal rubber dam
retainers were in contact with porcelain-fused-to-metal
(PFM) restorations.
84
Another study demonstrated
that neither the broad contact of a plastic retainer beak
nor the point contact under a metal retainer beak dam-
aged the contact area of porcelain surface of a PFM
cylinder.
85
However, repeated applications of rubber
dam clamps, in multiple appointments necessary to
complete endodontic procedures, is likely to increase
the risk of damage.
For endodontic treatment particularly, the use of
clamps with wings allows a more rapid, efficient means
of applying the rubber dam. A well-trained assistant is
able to perform much of the usual technical procedure
of application described later in this section. The wings
allow the dentist to place the clamp, dam, and frame in
one operation (Figure 9-59). In addition, the wings
cause a broader buccal-lingual deection of the dam
from the involved tooth, allowing increased access.
Rubber dam clamps undergo stress with repeated
use and sterilization. Additionally, clamps that are used
during endodontic procedures may be chemically
stressed and subject to fracture if in contact with the
irrigant sodium hypochlorite.
86
It is a good safety
measure to place dental oss ligatures around both
ends of the clamp bows so that if the clamp fractures,
both portions can be retrieved.
Forceps. Either the Ash- or Ivory-style clamp for-
ceps is satisfactory. One advantage of the Ivory forceps,
Figure 9-58 Le Cadre Articul rubber dam frame. A, In closed position, frame is curved to t face. B, Open position, from either side, allows
passage of radiographic lm holder. (Courtesy of Jored, Ormoy, France, and Trophy, USA.)
Table 9-14 Rubber Dam Clamp Selection
Maxillary Teeth
Central incisor Ivory 00 or 2, 212 or 9A,
Hu-Friedy 27, Ash A
Lateral incisor Ivory 00, 212 or 9A, Ash C
Canine Ivory 2 or 2A, 212 or 9A
Premolars Ivory 2 or 2A, Hu-Friedy 27
Molars Ivory 3 or 4, Ivory 8A, 12A or 13A,
14 or 14A, Ash A
Mandibular Teeth
Incisors Ivory 0 or 00, 212 or 9A, Ash C
Canine Ivory 2 or 2A, 212 or 9A
Premolars Ivory 2 or 2A, Hu-Friedy 27
Molars Hu-Friedy 18, Ivory 8A, 12A or
13A, 14 or 14A, 26, Ash A,
fatigued Ivory 2A
A B
however, is the projections from the engaging beaks.
These allow the operator the opportunity to exert a
gingivally directed force, which is often necessary to
direct the clamp beyond the height of contour and into
proximal undercuts.
The projections on the beaks also allow positive con-
trol, enabling the jaws of clamps to be tipped to depress
either the toe or heel of the clamp. The Ash-style
forceps beaks, on the other hand, afford a fulcrum
point for posterior or anterior rotation of the clamp.
Tucking Instrument. A plastic or cement instru-
ment is used to shed the rubber dam off the wings of
the clamp once the clamp has been positioned. It is also
used, along with a stream of air, to invert or tuck the
edges of the dam into the gingival sulci, thus ensuring
a moisture-proof seal. This is particularly necessary in
multiple-tooth applications.
Dental Floss. At one time it was recommended
that dental oss be routinely used as a ligature placed
around the cervix of each tooth to invert or tuck the
dam and provide a seal. Through the use of medium or
heavy dam material, this is no longer necessary. Floss is
still essential, however, for the testing of contacts
before dam application and for passing the dam mate-
rial through the contacts. In both instances, the opera-
tor should release his lingual grasp of the oss and pull
it out to the buccal, rather than back through the con-
tact point.
Saliva Ejector. Any disposable/radiolucent saliva
ejector is acceptable. It should always be placed under-
neath the dam for endodontic use, in contrast to the
procedure of cutting a hole through the dam. This will
398 Endodontics
prevent possible salivary contamination of the eld and
be less of a hindrance while taking radiographs with
the dam in place.
Technique of Application
Three methods of applying a rubber dam, two for a
single-bowed clamp and one for a double-bowed
clamp, are described in the following sections.
Preparation of Rubber Dam Application
Using a Single-Bowed Clamp
Dentist.
1. Remove supra- and subgingival calculus and
dental plaque. Mark the tooth to be treated with
a marker pen.
2. Select the clamp to be used.
3. Test contacts with oss to ensure passability and to
test for sharp edges that might tear the dam.
Assistant.
1. Punch one appropriate-sized hole just off center of
a 6 inch 6 inch piece of dam material. Rotate the
dam to match the tooth to be treated: upper or
lower, right or left. Traditionally, only the teeth
receiving therapy should be included in the dam
application.
2a. Stretch the dam over the frame and place the wings
of the selected clamp in the punched hole with the
bow of the clamp to the distal (Figure 9-60), or
2b. Place only the bow of the clamp through the
punched hole of the rubber dam.
3. Place the forceps in the clamp holes with tension and
hold in readiness for the dentist (see Figure 9-60).
Application by the Team Dentist.
4. Place an index nger in the vestibule to retract the
lip and cheek. The patient is instructed to place the
tongue on the opposite side.
5. Sight the tooth to be clamped between the jaws of
the clamp (Figure 9-61, A). Direct vision is essential.
6. Place the clamp into the cervical proximal under-
cuts on the tooth as the index nger is removed
from the vestibule (Figure 9-61, B). Finger pressure
is sometimes used to ensure seating of the clamp
7a. For 2a above, shed the dam off the clamp wings
with the tucking instrument (Figure 9-61, C). Care
is taken not to rip the dam, or
7b. For 2b above, loosely apply the rubber dam frame
to the corners of the rubber dam with the aid of the
assistant. Then stretch the dam under the wings of
the clamp with the tucking instrument and tighten
the rubber dam over the entire frame.
Figure 9-59 Placement of wings of clamp by assistant before posi-
tioning dam on frame. Bow of clamp is oriented to the distal.
Preparation for Endodontic Treatment 399
Figure 9-60 Assistant has mounted rubber dam on
frame and has positioned wings of clamp in dam. She
presents assembled unit with forceps to dentist, ready
for placement. Notice that hole is punched just off
center of 6 6-inch rubber dam. Position of hole is
identical for each tooth and dam is rotated for either
right or left side, upper or lower.
Figure 9-61 A, Dentist retracts lip and cheek with thumb and index nger of left hand and sites tooth to be clamped (here a maxillary pre-
molar) between bows of the clamp. Care must be taken not to clamp wrong tooth. B, Clamp is carried into gingival undercuts. If undercuts
are slight, clamp may be rotated on tooth to take advantage of undercuts along labial and lingual-proximal long axis. C, Dam is shed from
clamp wings with tucking instrument, which is also used to carry lip of dam under gingival sulcus after tooth is air-dried. D, Dental oss is
used to carry dam past interproximal contacts. Floss should then be pulled to buccal rather than removed back past contact.
8. Use oss to aid in passing the dam through contacts.
Pull the oss through the labial or buccal rather than
pulling back through the contacts (Figure 9-61, D).
9. In multiple-tooth applications, tuck the dam into
the gingival sulci of the unclamped teeth, using the
tucking instrument.
Assistant.
10. Use compressed air to dry the teeth; this aids in
tucking.
11. Aid in tightening the rubber dam over the frame
once the clamp is on the tooth and after the rubber
dam is stretched under the wings of the clamp.
12. Place the saliva ejector under the dam. On a maxil-
lary dam application, many patients do not need
the saliva ejector.
Preparation of Rubber Dam Application Using a
Double-Bowed Clamp
Dentist.
Same as for a single-bowed clamp.
Assistant.
1. Punch one large hole just off center of a 6 inch 6-
inch piece of dam material.
2. Stretch the dam over the frame
Application by the Team Dentist.
1. After the assistant has positioned the dam over the
involved and marked tooth (Figure 9-62, A), place
the clamp into the cervical proximal undercuts on
the tooth.
2. Use oss to aid in passing the dam through the
contacts (Figure 9-62, B).
400 Endodontics
Assistant.
1. Stretch the rubber dam over the marked tooth to
be isolated (see Figure 9-62, A).
2. Ensure that the rubber dam is not blocking the
patients nose.
3. Place the saliva ejector under the dam.
Completed dam application should take less than 30
seconds of the dentists time in all but the unusual
cases. In applying the dam to a single tooth, however,
the dentist must take great care that the correct tooth
is clamped. After placement, the record is checked and
the teeth are counted under the dam, rst by the den-
tist and then independently by the assistant.
The team that is hesitant about clamping the wrong
tooth must be cautioned about using the time-honored
system of rst placing the clamp, then the dam, then
the frame. This sequence of rubber dam application
may lead to accidental swallowing of a rubber dam
clamp. There are several reports in the literature on the
ingestion of rubber dam clamps.
8789
This further
emphasizes the importance of using oss ligatures
around rubber dam clamps so that dislodged clamps
and broken clamps can be retrieved quickly.
87-90
Removal of Dam
1. For single-tooth applications, simply remove the
clamp with the forceps and remove the dam.
2. In multiple-tooth applications, rst remove the
clamp, then place a nger under the dam in the
vestibule, and stretch the dam to the facial, away
from the teeth. Cut the stretched interproximal dam
with scissors and then remove the dam. After
removal, it is essential that the dam be inspected to
Figure 9-62 A, Rubber dam in place, exposing involved tooth previously marked with a marking pen. B, Clamp placement in gingival
undercuts. Dental oss carries dam past interproximal contacts and is removed by pulling to buccal rather than back through contacts.
(Courtesy of Jeffrey M Coil.)
A B
Preparation for Endodontic Treatment 401
ensure that no interproximal dam septum has been
left between the teeth.
Circumstances Requiring Variations from the
Usual Application
A number of circumstances require a variation from
the standard dam application.
First Circumstance. A well-done gingival gold ll-
ing or PFM veneer crown on the involved tooth that
could be damaged by clamps.
Variation. Clamp one tooth posterior to, and
extend the rubber dam one tooth anterior to, the
involved tooth.
Second Circumstance. Multiple adjacent teeth
requiring treatment.
Variation. The posterior tooth is clamped normally
while the clamp is reversed (with the bow pointing
mesially) on the more anterior tooth. By another
approach, the most posterior tooth is clamped normally,
while the anterior portion of the dam is retained and
retracted without a clamp. Neaverth has suggested that a
1
4-inch-wide strip of dam can be stretched thin to simu-
late dental oss (personal communication, Feb. 2000). It
is then passed through the contact and, when released,
acts as a wedge holding the dam in place (Figure 9-63).
Third Circumstance. Bridge abutments, splints,
and orthodontic bands with wires.
Variation. Punch a larger-than-usual hole in the
dam. Smear Oraseal around the hole on the underside of
the dam. This mucilaginous material prevents leakage.
Clamp the tooth in the normal manner. In addition, place
a round toothpick through the gingival embrasure next
to the pontic. If leakage is still a problem, add more
Oraseal around the abutment at the site of the leakage.
Fourth Circumstance. Partially erupted tooth.
Variation. An Ivory #14A or Ash #A clamp forced
subgingivally into the cervical undercut will often hold.
On occasion, an Ash #C clamp, placed on the oblique,
will suffice. For supragingival retention, when no
undercut is present, Japanese researchers have recom-
mended placing a small amount of self-curing compos-
ite resin on the labial and lingual unetched enamel sur-
faces. The clamp is set in this scaffold of the cured resin.
After use, the resin can be lifted off with an excavator.
91
Fifth Circumstance. Caries, resulting in a subgin-
gival restorative margin of the involved tooth (Figure
9-64, A).
Variation. Clamp one tooth posterior to, and
extend rubber dam one or two teeth anterior to, the
involved tooth. The furthest anterior tooth isolated may
receive a rubber dam clamp with its bow pointing
mesially. If oss shreds through, or the rubber dam rips
between the contacts, Oraseal may be necessary to
develop a uid seal (Figure 9-64, B). This multiple-tooth
isolation facilitates easy placement of an interproximal
Figure 9-63 Narrow strip of rubber dam (arrow) passed through
contact point acts as wedge to hold dam anteriorly without addi-
tional clamp. (Courtesy of Dr. E.J. Neaverth.)
Figure 9-64 A, Four-tooth and two-clamp dam isolation in patient
with Dilantin hyperplasia. B, Possible leakage toward the buccal and
lingual is controlled by Oraseal. (Courtesy of Jeffrey M. Coil.)
A
B
matrix used during nal restoration, without interfer-
ence from a rubber dam clamp on the involved tooth.
Sixth Circumstance. Hemisected maxillary or
mandibular molars.
Variation. Hemisected mandibular molars are
treated as a premolar. Those that are wide buccolin-
gually are best clamped with a fatigued Hu-Friedy or
Ivory #2 or #2A.
A hemisected maxillary molar with the lingual root
remaining is also best treated as a large premolar. A Hu-
Friedy #27 clamp frequently adapts well. When the two
buccal roots of a maxillary molar remain, it is then best
treated as a small molar, and an Ash #A frequently suf-
ces. Often the hemisected maxillary molar can be
clamped only by placing the clamp obliquely.
Seventh Circumstance. Full-crown preparation
without a cervical undercut to retain the clamp.
Variations. A proper full-crown preparation will
shed toward the occlusal, and the clamp may not pro-
vide adequate resistance to the tension of the rubber
dam. It may be necessary to place parallel horizontal
grooves on the buccal and lingual axial walls of the
preparation near the gingival margin to permit the
clamp to grasp onto the preparation. The Ivory #2 or
#2A clamp will t into these grooves for retention. It
has also been suggested that applying composite resin
on the buccal and lingual unetched surfaces might be
superior to cutting grooves.
91
Eighth Circumstance. Posterior teeth with mini-
mal tooth structure for clamp retention.
Variation. The tension of the rubber dam as it is
stretched taut over the frame exerts pressure, or a force
402 Endodontics
of displacement, on the bow of the clamp. The clamp
may be reversed on the working tooth; a second clamp
is placed over the rubber damon the next tooth poste-
rior to absorb the pressure of the rubber dam.
Periodontal crown lengthening to elongate the
crown of a fractured or badly decayed tooth was dis-
cussed in the section Endodontic Pretreatment.
Ninth Circumstance. Extensive caries resulting in
subgingival buccal and/or lingual margin(s).
Variation. The involved tooth can undergo peri-
odontal crown lengthening, addition of restorative
material to allow for supragingival clamp placement, or
gingival surgery to expose more tooth structure to
allow for clamp placement (see Figure 9-51).
Tenth Circumstance. Fractured cusp with subgin-
gival margin on buccal or lingual surface.
Variation. Use three-tooth rubber dam isolation
as in second circumstance. By placing a short cotton
roll under the wing of the rubber dam clamp, addi-
tional reection of the rubber dam can be achieved
(Figure 9-65). Note that the clamp would otherwise be
unstable if placed on the involved tooth in the tradi-
tional single-tooth isolation.
Eleventh Circumstance. Tooth with calcied pulp
chamber and canal(s).
Variation. Use three-tooth rubber dam isolation
as in second circumstance. Involved tooth is without a
clamp, allowing the operator to better visualize the CEJ
region of the tooth. There are no clamp wings to
obstruct ones view. A periodontal probe can be traced
along the root surface to orientate oneself to the
crownroot angulations during difficult-access cavity
preparations. Additionally, the image in working lms
is unlikely to be obstructed by the clamp (Figure 9-66).
Figure 9-65 Placement of cotton roll (arrow) under the palatal
wing of the clamp stretches the dam against the palate, exposing
more of the fractured tooth surface. Seal can be augmented with
Oraseal. (Courtesy of Jeffrey M. Coil.)
Figure 9-66 Fractured rst molar isolated in three-tooth dam
placement with clamp on second molar, allowing unobstructed view
of canal orices in rst molar. Distal canal marked by gutta-percha to
visualize correct drilling direction. (Courtesy of Jeffrey M. Coil.)
Preparation for Endodontic Treatment 403
SUMMARY
Students, recent graduates, and veteran practitioners
alike will nd restorative and endodontic practice more
rewarding and less frustrating as their mastery of rubber
dam applications increases. The use of simplied tech-
niques, improved materials, and organized procedures,
as well as patience, practice, and perseverance, will has-
ten this mastery. Remember, it is imperative that a rub-
ber dam be used for all endodontic procedures!
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