ARNALDO CASTELLUCCI MD, DDS

ENDODONTICS Volume 1

Foreword
JOHN D. WEST, DDS, MSD
H
IO IS
IT GL
N
ED EN
W

IL TRIDENTE
NE

EDIZIONI ODONTOIATRICHE
ENDODONTICS
This Book is dedicated in memory of

my loving Mother and Father.

In scientific questions, opinions and views of any kind

should not be transmitted from one man to another,

from one textbook to another, or from one generation

to another, unless they are based upon actual findings.

Opinion cannot be substituted for scientific evidence.

Balint Orban, M.D., J.A.D.A., 1930

IL TRIDENTE
EDIZIONI ODONTOIATRICHE

DTP & Cover Sheet: - Florence, Italy

Photolitograph: - Florence, Italy
Printed by: Arti Grafiche - Signa, Italy - 2004, June

Previous italian edition copyrighted 1993

ISBN 88-89411-00-7

FIRST EDITION

Copyright © 2004 by Edizioni Odontoiatriche Il Tridente S.r.l.

IL TRIDENTE
EDIZIONI ODONTOIATRICHE

All right reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in
writing from the publisher. Permission may be sought directly from Edizioni Odontoiatriche Il Tridente S.r.l. in Florence,
Italy: phone +39 055 500 1312, fax +39 055 500 0232, e-mail: info@iltridente.it.

Edizioni Odontoiatriche Il Tridente S.r.l.

Viale dei Mille 60
50131 Florence, Italy
E NDODONTICS

Edited by

ARNALDO CASTELLUCCI, MD, DDS

Visiting Professor of Clinical Endodontics, University of Florence Dental School, Italy
President, Warm Gutta-Percha Study Club
Founder and Director, Micro-Endodontic Training Center, Florence, Italy

Foreword by

JOHN D. WEST, DDS, MSD

Associate Professor, Department of Endodontics, University of Washington School of
Dentistry, Seattle, Washington
Clinical Instructor, Department of Endodontics,Boston University, Henry Goldman School of
Dental Medicine
Guest Faculty, Pacific Endodontic Research Foundation
Founder and Director, Center of Endodontics, Tacoma, Washington

IL TRIDENTE
EDIZIONI ODONTOIATRICHE

Edizioni Odontoiatriche Il Tridente - Firenze

F OR EWOR D TO THE F IRST I TALIAN E DITION

October 6, 1992

Endodontics world wide has developed rapidly in the last quarter century.
In the United States alone more than 3,500 dentists now limit their practices to endodontics and over
100,000 general dentists successfully treat endodontic cases.
ere is nothing to prevent similar development of endodontic practice in Europe in the years ahead.
is process will surely be accelerated with the Unification of Europe and the further development of the
Common Market, professionally and academically, no less than commercially.
It is significant that Dr. Castellucci’s book ENDODONZIA is being published in Italian, and at this time.
Italian dentistry is enjoing a renaissance no less spectacular than the intellectual, cultural, and artistic
renaissance experienced in Florence in the 13th century.
Nowhere in Europe presently is modern endodontics so much appreciated and nowhere does the
profession reach out for more information about this vital field.
is comprehensive work covers the depth and breadth of endodontics admirably. With great skill and
love for the material, Dr. Castellucci has delivered a text that is both interesting and informative. He has
organized his book from the early history of endodontics to the restoration of endodontically treated teeth.
In between no detail is omitted in describing the methods of treatment necessary for clinical success. e
careful reader will find everything here for the proper management of endodontic problems and for the
mastery of endodontic technique.
e book is arranged exquisitely, balancing intelligent scholarly text with outstanding visual material. It
is eminently readable, making it a happy adventure in obtaining endodontic knowledge.
As is well known, the most critical clinical aspects of endodontics are Cleaning and Shaping of Root
Canal Systems and ree Dimensional Obturation, thereafter.
e chapters devoted to these subjects are outstanding as is the chapter on the equally critical subject,
Endodontic/Periodontic Relation. ey alone merit the reading of this book, but for the fortunate reader
there is more, much more to be found here.
I recommend Dr. Castellucci’s book wholeheartedly to any dentist (colleague) who contemplates
incorporating modern endodontics into his/her practice. It is a significant contribution to this field!

Herbert Schilder, DDS

Professor and Chairman
Department of Endodontics
F OR EWOR D
COLLEGE OF ENDODONTICS
Seattle, Washington, USA
© 1994-2004, University of Washington
U N I V E R S I T Y O F
WASHINGTON
April 19, 2004

For the second time in a decade, Arnaldo Castellucci has created the best endodontic textbook in the world.
Perhaps the reason for this assertion is that ENDODONTICS addresses the one word that best describes endodontics
in this fi rst decade of the third millennium. That word is CHANGE. Arnaldo Castellucci addresses this change, teaches
us how to learn from this change and then challenges us, all of us, to embrace endodontic change.
This unprecedented work presents new ways of thinking and the changes in 21st Century endodontic technologies.
Castellucci’s trilogy of endodontics is a practical and profound fi lter for the modern endodontic clinician to learn why,
when, and how to experience newfound clinical artistry based on proven biologic principles.
ENDODONTICS differentiates itself as a signifi cant endodontic resource in fi ve critically distinctive domains.
First, its author, Arnaldo Castellucci, is a towering fi gure in the development of advanced endodontics throughout
the world, particularly in Europe. His 25-year love affair with endodontics is characterized by clinical excellence,
sacrifi ce, ethics, integrity and a desire to teach in a way that his students feel reverence for their endodondic
experience. In addition, his students learn essential knowledge and skills. Arnaldo has established a rich legacy
of producing the highest quality of education for his students’ learning. ENDODONTICS is an expression of his
dedication to making that difference.
Second, ENDODONTICS combines the art and science of clinically relevant modern endodontics. From the
evolutionary history to endodontic pretreatment in Volume I, cleaning and shaping and 3D obturation in Volume
II, and interdisciplinary endodontics to restoration in Volume III, readers who benefi t the most are the ones who
understand the principles of this book. Doctors will then be able to adjust their treatment and treatment planning as
technologies change and knowledge grows.
Third, Arnaldo Castellucci has assembled an impressive list of contributors. Each is a great teacher and a great
thinker.
These authors are a credit to Arnaldo’s vision of comprehensive endodontics that teaches not only endodontic
principles and techniques but the relationship of endodontics to esthetic and restorative dentistry.
Fourth, the sheer volume of knowledge and thoroughness of every subject makes ENDODONTICS an unmatched
one-stop endodontic reference.
Finally, the fi rst edition of ENDODONTICS was largely a refl ection of Professor Herbert Schilder’s teachings and
words. In Castellucci’s second book, Schilder’s infl uence continues in Castellucci Style.
And so it is with love, possibility, and an “if I can do it, you can do it” context that Arnaldo Castellucci has
written this modern endodontic textbook. If read from cover to cover, the reader learns successful endodontics and is
challenged to want more. Arnaldo invites us to make endodontics playful. And then endodontics will be fun.
Every professional, at some time in their career, feels the need to do more than what is required of them. They
want to excel. They want to master their craft and have that mastery impact their lives through performance and
fulfi llment at the highest level possible in their fi eld. ENDODONTICS is that invitation…it is the invitation to go
beyond our self.

John D. West, DDS, MSD

Affi liate Associate Professor
University of Washington School of Endodontics
Clinical Instructor
Boston University Henry M. Goldman School of Dental Medicine
VIII

P R EFACE AND ACKNOWLEDGEMENTS

In the eleven years that have passed since the publication of the first edition in Italian of my book
Endodontics, there has been a real explosion in new technology, new instruments and new materials,
necessitating the need for revision and updating. The new rotary instruments in Nichel Titanium are
widely and universally accepted, and have simplified the most complex part of the root canal treatment,
namely the shaping. Their use in fact makes root canal preparation more rapid, more efficient, with
results that are certainly more predictable. Consequently there is reduced stress for both patient and
clinician and ultimately one can obtain a preparation that is extremely conservative having the advantage
of maintaining the strength of the endodontically treated tooth and therefore increasing its longevity.
Apart from the gutta-percha vertical compaction technique described by Prof. Schilder, well known and
widely used around the world, other techniques of heated filling have been affirmed or introduced in the
past decade namely, the Thermafil Technique presented by Dr. Ben Johnson and the Continuous Wave
Technique described by Dr. Stephen Buchanan.
A new canal obturation material has recently become available as a substitute for gutta-percha:
this material is resinous with all the physical characteristics of gutta-percha (thermoplastic, soluble in
chloroform) but also guarantees adhesion to the dentinal wall and therefore an even better seal.
Prof. Mamoud Torabinejad, from the Loma Linda University in California, has studied and validated a
biocompatible and above all hydrophilic material for the treatment of perforations, immature apices, pulp
exposures and that can also be used in surgery for retrograde filling, has literally changed the approach of
operators confronted with the above clinical situations enabling large numbers of teeth to be saved, which
would have otherwise been condemned to extraction or a certainly long treatment time, with a more
uncertain prognosis.
Ultrasonics currently are not used exclusively for oral hygiene procedures on our patients, but have
an infinite number of uses in the endodontic field, namely removal of posts and screws, the removal of
calcifications, old filling material in the pulp chamber, the finishing of the access cavity, the exposure
of the mesio palatine canal of the mesio buccal root of the upper first molar, the removal of fractured
instruments and silver cones, as well as retrograde cavity preparation in the endodontic surgery.
But the greatest revolution that has occurred in the last decade has certainly been the widespread use
of the operatory microscope. This is essentially due to people like Gary Carr of San Diego California.
Today in the specialist endodontic schools of North America and in many other parts of the world,
endodontics is taught and carried out using the microscope. The canal has ceased to be “a black hole” in
which one works aided by tactile sensitivity and that which one can “see” only by attentive examination
of a radiograph. Currently, whatever difficulty that is present in the straight part of the root canal, even if
in the most apical third, is easily seen and resolved thanks to the magnification and coaxial illumination
that an operatory microscope guarantees.
The operating microscope has radicallly transformed Surgical Endodontics into a microsurgical
procedure. All the surgical phases can be carried out with the use of the microscope: the incision, the
root end preparation and filling as well as the suturing. This has dramatically increased the predictability
of the results, improved the prognosis, raised the quality of success and by no means last, reduced the
operator’s stress.
In surgical endodontics the microscope enables careful examination of the accuracy of ones incision,
preparation, retrograde filling and suturing, with an increase in predictability of results, and a better
prognosis and higher percentage of success.
For all these reasons after eleven years since the publication of the first edition I felt the need to
update it, making available to students and clinicians the necessary information. Furthermore, driven
 IX

by the success which the preceeding edition also had abroad, the work is published in English with the
contribution of many colleagues and friends that offered to help me with this by no means easy task.
Concerning this I would like to express my aknowledgement to the numerous Italian and foreign
contributors, who with their contribution have given prestige to this work.
Therefore my thanks to:
To Dr. Mario Lendini from Turin, Italy, author of the chapter on Digital Radiography
To Dr. Uziel Blumenkranz from Washington, Washington DC, coauthor of the chapter on Periapical
Pathology and in particular on the section about The Cracked Tooth Syndrome
To Dr. Kirk A. Coury from Amarillo, Texas coauthor of the chapter on Anaesthesia
To Dr. Stefano Patroni from Piacenza and to Dr. Paolo Ferrari from Parma, Italy, authors of the chapter on
Pretreatment
To Prof. Elio Berutti from Turin, Italy, coauthor of the chapters on Endodontic Instruments, Shaping and
Cleaning and Nickel Titanium
To Prof. Giuseppe Cantatore from Rome, Italy, coauthor of the chapters on Endodontic Instruments,
Nickel Titanium and the Thermafil System
To Dr. Michael Scianamblo from San Francisco, California, author of the chapter on The Technique of
Precocious Coronal Enlargement
To Dr. Clifford J. Ruddle from Santa Barbara, California, author of the chapter on The Protaper System and
the chapter on Retreatment
To Dr. Stephen L. Buchanan from Santa Barbara, California, author of the chapter on The GT System and
The Continuous Wave Condensation
To Dr. Richard E. Mounce from Portland, Oregon, author of the chapter on The K3 System
To Dr. John T. McSpadden from Lookout Mountain, Georgia, coauthor of the chapter on The Quantec
System
To Dr. Gary D. Glassman and Kenneth Serota from Toronto, Canada, coauthor of the chapter on The
Quantec System
To Dr. W. Ben Johnson from Tulsa, Oklahoma, coauthor of the chapter on The Thermafil System
To Prof. Vito Antonio Malagnino and to Dr. Paola Passariello from Rome, Italy, coauthors of the chapter
on the Microseal System
To Dr.Ronal R. Lemon from New Orleans, Louisiana, coauthor of the chapter on Bleaching
To Dr. Gary B. Carr from San Diego, California, coauthor of the chapter on Microscopes
To Dr. John J. Stropko from Scottsdale, Arizona, author of the chapter on Endodontic Microsurgery
To Dr. Riccardo Becciani from Florence, Italy, author of the chapter on the Testoration of the
Endodontically Treated Teeth
My thanks go to Dr. Ian Watson from Toronto, Canada and to Dr. John Theunissen from Massa, Italy,
for their valuable help with the English translation of this work.
Furthermore I would like to express profound gratitude to my friend John D. West from Tacoma,
Wahsington, for the touching words he has seen fit to use in the preface of this work.
Finally I would like to dedicate this book to he, whom I owe everything to, and who has literally
changed the course of my life, from whom I learned everything which I am now proud to teach. That is
my esteemed Teacher, Prof. Herbert Schilder.
X

C ONTRIBUTORS

RICCARDO BECCIANI, MD, DDS

Visiting Professor of Restorative Dentistry, Univeristy of Siena Dental School, Siena, Italy.

ELIO BERUTTI, MD, DDS

Professor and Chairman of Endodontics, Univeristy of Turin Dental School, Turin, Italy; Past President of the
Italian Society of Endodontics.

UZIEL S. BLUMENKRANZ, DDS

Private Practice limited to Endodontics, Washington, Washington DC, USA; Past President of the Venezuelan
Endodontic Society.

STEPHEN L. BUCHANAN, DDS, FACD, FICD

Founder, Dental Education Laboratories; Adjunct Clinical Professor, Department of Endodontics, University of
the Pacific School of Dentistry, San Francisco, California, USA; Diplomate, American Board of Endodontics.

GIUSEPPE CANTATORE, MD, DDS

Associate Professor, Department of Endodontics, University of Verona Dental School, Verona, Italy; Private
Practice limited to Endodontics, Rome, Italy.

GARY B. CARR, DDS, MSD

Founder and Director, Pacific Endodontic Research Foundation, San Diego, California, USA; Lecturer,
University of California at Los Angeles; Consultant in Endodontics, VA Medical Center Long Beach, California;
Diplomate, American Board of Endodontics.

ARNALDO CASTELLUCCI, MD, DDS

Visiting Professor of Clinical Endodontics, University of Florence Dental School, Florence, Italy; President, Warm
Gutta-Percha Study Club; Founder and Director, Micro-Endodontic Training Center, Florence. Past President
of the Italian Society of Endodontics; Past President of the International Federation of Endodontic Associations;
Editor of the “Italian Journal of Endodontics” and of “The Endodontic Informer”.

KIRK A. COURY, DDS, MS

Private Practice Limited to Endodontics, Amarilli, Texas, USA; Diplomate, American Board of Endodontics.

PAOLO FERRARI, DDS

L.M.D. University of Geneva; Private Practice, Parma and Piacenza, Italy.

GARY D. GLASSMAN, DDS, FRCD(C)

Fellow and Examiner for the Royal College of Dentist of Canada; Fellow of the Academy of Dentistry
International; Fellow of the Academy of Dental-Facial Aesthetics; Endodontic Editor for Oral Health; Past
President of the Gorge Hare Endodontic Study Club.

W. BEN JOHNSON, DDS

Clinical Professor Louisiana State University School of Dentistry, New Orleans, Louisiana; Clinical Associate
Professor Baylor College of Dentistry, Dallas, Texas; Fellow of the Pierre Fauchard Academy; Fellow
International College of Dentists; Private Practice limited to Endodontics, Tulsa, Oklahoma, USA.

RONALD R. LEMON, DMD

Professor and Chairman, Department of Endodontics, LSUHSC School of Dentistry, New Orleans, Louisiana,
USA; Diplomate, American Board of Endodontics.
 XI

MARIO LENDINI, DDS

Private Practice, Turin, Italy.

VITO ANTONIO MALAGNINO

Professor and Chairman of Endodontics, Univeristy of Chieti Dental School “G. D’Annunzio”, Chieti, Italy; Past
President of the Italian Society of Endodontics; Past President of the Italian Society of Restorative Dentistry,
S.I.D.O.C.; Editor of the Italian Journal of Endodontics; Co-Editor of the Italian Journal of Restorative Dentistry;
Honorary Member of the French Society of Endodontics.

JOHN T. MCSPADDEN, DDS

International lecturer and researcher, Lookout Mountain, Georgia, USA.

RICHARD E. MOUNCE, DDS

Private Practice limited to Endodontics, Portland, Oregon, USA.

PAOLA PASSARIELLO
Visiting Professor of Endodontics, Univeristy of Chieti Dental Scool “G. D’Annunzio”, Chieti, Italy; Private
Practice limited to Endodontics, Rome, Italy.

STEFANO PATRONI, MD, DDS

L.M.D. University of Geneva, Private Practice, Piacenza, Italy.

CLIFFORD J. RUDDLE, DDS, FACD, FICD

Assistant Professor, Deparment of Graduate Endodontics, Loma Linda University, Loma linda, California,
USA; Adjunct Assistant Professor, Department of Endodontics University of the Pacific School of Dentistry, San
Francisco, California; Consultant Department of Graduate Endodontics Long Beach Veterans Medical Center,
Long Beach, California, USA.

MICHAEL J. SCIANAMBLO, DDS

Associate Professor at the University of California, School of Dentistry, San Francisco; Fellow of the Harvard
School of Dental Medicine, USA.

KENNETH S. SEROTA, DDS, MMSC

Fellow of the Academy of Dentistry International; Fellow of the Pierre Fauchard Academy; Founder of ROOTS
– www.rxroots.com; Program Coordinator, Continuing Education Department, University of Toronto Faculty of
Dentistry, Toronto, Canada.

JOHN J. STROPKO, DDS

Private Practice of Endodontics, Scottsdale, Arizona, USA; Visiting Clinical Instructor, Pacific Endodontic
Research Foundation, San Diego, California; Adjunct Assistant Professor Graduate Endodontics Goldman
School of Dental Medicine, Boston, Massachusetts; Assistant Professor Graduate Clinical Endodontics Loma
Linda University School of Dentistry, Loma Linda, California; Instructor and Co-Founder Clinical Endodontic
Seminars, Scottsdale, Arizona.
XII

C ONTENTS
VOLUME I
CHAPTER 1 A BRIEF HISTORY OF ENDODONTICS by Arnaldo Castellucci

CHAPTER 2 EMBRIOLOGY by Arnaldo Castellucci

CHAPTER 3 DEFINITION, SCOPE AND INDICATIONS by Arnaldo Castellucci

FOR ENDODONTIC THERAPY

CHAPTER 4 DIAGNOSIS IN ENDODONTICS by Arnaldo Castellucci

CHAPTER 5 ENDODONTIC RADIOGRAPHY by Arnaldo Castellucci

CHAPTER 6 DIGITAL RADIOGRAPHY SYSTEMS (DRS) by Mario Lendini

CHAPTER 7 PULPAL PATHOLOGY by Arnaldo Castellucci

CHAPTER 8 PERIAPICAL DISEASE by Arnaldo Castellucci

and Uziel Blumenkranz

CHAPTER 9 THE USE OF ANESTHESIA IN ENDODONTICS by Arnaldo Castellucci

and Kirk A. Coury

CHAPTER 10 TOOTH ISOLATION: THE RUBBER DAM by Arnaldo Castellucci

CHAPTER 11 ACCESS CAVITY AND ENDODONTIC ANATOMY by Arnaldo Castellucci

CHAPTER 12 PRETREATMENT: by Stefano Patroni

PREPARATION TECHNIQUES FOR ENDODONTIC THERAPY and Paolo Ferrari
VOLUME II
CHAPTER 13 ENDODONTIC INSTRUMENTS by Elio Berutti
and Giuseppe Cantatore

CHAPTER 14 CLEANING AND SHAPING THE ROOT CANAL SYSTEM by Arnaldo Castellucci
and Elio Berutti

CHAPTER 15 SCHILDER’S TECHNIQUE FOR SHAPING THE ROOT CANAL SYSTEM by Arnaldo CastelluccI

CHAPTER 16 A CONTEMPORARY APPROACH TO CLEANING AND SHAPING by Michael Scianamblo

THE ROOT CANAL SYSTEM EMPHASIZING
“EARLY CORONAL ENLARGEMENT”

CHAPTER 17 CURVED CANALS by Arnaldo Castellucci

 XIII

CHAPTER 18 ROTARY INSTRUMENTS IN NICKEL-TITANIUM by Elio Berutti

and Giuseppe Cantatore

CHAPTER 19 THE PROTAPER TECHNIQUE by Clifford Ruddle

CHAPTER 20 THE PREDEFINED ENDODONTIC PREPARATION. by Stephen L. Buchanan

CONCEPTS, INSTRUMENTS, AND TECHNIQUES
FOR THE GREATER TAPER SYSTEM

CHAPTER 21 THE K3 ROTARY NICKEL TITANIUM INSTRUMENTS SYSTEM by Richard E. Mounce

CHAPTER 22 THE QUANTEC ROTARY NITI INSTRUMENTATION SYSTEM by John McSpadden,

Gary Glassman and
Kenneth S. Serota

CHAPTER 23 OBTURATION OF THE ROOT CANAL SYSTEM: by Arnaldo Castellucci

BIOLOGICAL PRINCIPLES, MATERIALS AND TECHNIQUES

CHAPTER 24 THE SCHILDER TECHNIQUE OF VERTICAL COMPACTION OF by Arnaldo Castellucci

WARM GUTTA-PERCHA

CHAPTER 25 THE CONTINUOUS WAVE OF CONDENSATION by Stephen L. Buchanan

CHAPTER 26 THE THERMAFIL SYSTEM by Giuseppe Cantatore

and W. Ben Johnson

CHAPTER 27 THE MICROSEAL TECHNIQUE by Vito Antonio Malagnino

and Paola Passariello
VOLUME III
CHAPTER 28 ENDODONTIC-PERIODONTIC INTERRELATIONSHIP by Arnaldo Castellucci

CHAPTER 29 THE TREATMENT OF TEETH WITH IMMATURE APICES by Arnaldo Castellucci

CHAPTER 30 ROOT RESORPTIONS by Arnaldo Castellucci

CHPATER 31 BLEACHING ENDODONTICALLY TREATED TEETH by Arnaldo Castellucci

and Ronald Lemon

CHAPTER 32 THE USE OF THE SURGICAL OPERATIVE MICROSCOPE by Gary B. Carr

IN ENDODONTICS and Arnaldo Castellucci

CHAPTER 33 MICRO-ENDODONTIC NONSURGICAL RETREATMENT by Clifford J. Ruddle

CHAPTER 34 MICRO-SURGICAL ENDODONTICS by John J. Stropko

CHAPTER 35 RESTORATION OF THE ENDODONTICALLY TREATED TEETH by Riccardo Becciani

XIV

C URRICULUM VITAE

Dr. Castellucci graduated in Medicine at the University of Florence in 1973 and he specialized
in Dentistry at the same University in 1977. From 1978 to 1980 he attended the Continuing
Education Courses on Endodontics at Boston University School of Graduate Dentistry and in 1980
he spent four months in the Endodontic Department of Prof. Herbert Schilder. Since then, he has a
limited practice on Endodontics.
Active Member of the Italian Endodontic Society S.I.E. since 1981, in 1982 he was elected in the
Board of Directors of the Society where he worked as Scientific Advisor, Secretary Treasurer, Vice
President and lately as President in 1993-95.
Active Member of the European Society of Endodontology E.S.E., he was the Secretary in 1981-
83.
He is Active Member of the American Association of Endodontists A.A.E. since 1985.
He is Active Member of the Italian Society of Restorative Dentistry S.I.D.O.C. since 1992.
He has been the President of the International Federation of Endodontic Associations I.F.E.A.
in 1990-92.
From 1983 to 2000 he has been Professor of Endodontics at the University of Siena Dental
School. Now is Visiting Professor of Endodontics at the University of Florence Dental School.
He translated into Italian the text on “Clinical and Surgical Endodontics. Concepts in
Practice”, by Frank, Glick, Simon and Abou-Rass.
He is the Editor of “The Italian Endodontic Journal” and of “The Endodontic Informer”. He is
also the Founder and President of the “Warm Gutta-Percha Study Club”.
He published articles on Endodontics in the most prestigious Endodontic Journals.
He is the author of the text “Endodonzia”, which now is available in the English language.
He is Founder and President of the Micro-Endodontic Training Center in Florence, where he
teaches and gives hands-on courses on nonsurgical and surgical Endodontics.
International lecturer, he gave presentations at National and International Congresses in Brasil,
Canada, Colombia, England, France, Germany, Israel, Lebanon, Mexico, Monaco, Russia, Spain,
Switzerland, United States, Venezuela.
 XV

C ONTRIBUTORS
Volume I

UZIEL BLUMENKRANZ, DDS

Private Practice limited to Endodontics, Washington, Washington DC, USA
Past President of the Venezuelan Endodontic Society.

ARNALDO CASTELLUCCI, MD, DDS

Visiting Professor of Clinical Endodontics, University of Florence Dental
School, Italy; President, Warm Gutta-Percha Study Club; Founder and
Director, Micro-Endodontic Training Center, Florence, Italy

KIRK A. COURY, DDS, MS

Diplomate, American Board of Endodontics

PAOLO FERRARI, DDS

L.M.D. University of Geneva, Switzerland
Private Practice, Parma and Piacenza, Italy.

MARIO LENDINI, DDS

Practice limited to Endodontics, Turin, Italy

STEFANO PATRONI, DDS

L.M.D. University of Geneva, Switzerland
Private Practice, Piacenza, Italy.
XVI

C ONTENTS
Volume I

CHAPTER 1 A BRIEF HISTORY OF ENDODONTICS .................................................................................. 2

ARNALDO CASTELLUCCI

Bibliography.......................................................................................................................... 5

CHAPTER 2 EMBRYOLOGY ........................................................................................................................ 6

ARNALDO CASTELLUCCI

Crown formation .................................................................................................................. 6

Root formation...................................................................................................................... 14
Single- and multiple-root formation .................................................................................... 16
The formation of lateral canals ............................................................................................ 17
Exposed dentin and enamel pearls ..................................................................................... 20
Function and fate of dental lamina...................................................................................... 21
Bibliography.......................................................................................................................... 23

CHAPTER 3 DEFINITION, SCOPE, AND INDICATIONS FOR ENDODONTIC THERAPY ............................... 24

ARNALDO CASTELLUCCI

Basic phases of endodontic therapy.................................................................................... 25

Indications and contraindications ........................................................................................ 26
True contraindications ..................................................................................................... 27
False contraindications .................................................................................................... 29
True indications ............................................................................................................... 39
Strategic endodontics....................................................................................................... 40
Bibliography.......................................................................................................................... 43

CHAPTER 4 DIAGNOSIS IN ENDODONTICS ............................................................................................... 44

ARNALDO CASTELLUCCI

Subjective information.......................................................................................................... 44
Medical history................................................................................................................. 44
Dental history................................................................................................................... 44
Objective information........................................................................................................... 46
Examination ..................................................................................................................... 46
Percussion ........................................................................................................................ 47
 XVII

Palpation .......................................................................................................................... 47
Radiographic examination............................................................................................... 48
Thermal tests.................................................................................................................... 56
Electric pulp test .............................................................................................................. 59
Cavity test......................................................................................................................... 62
Anesthesia test ................................................................................................................. 62
Transillumination ............................................................................................................. 64
Bite test............................................................................................................................. 64
Bibliography.......................................................................................................................... 65

CHAPTER 5 ENDODONTIC RADIOGRAPHY ............................................................................................... 66

ARNALDO CASTELLUCCI

Basic principles of radiology ............................................................................................... 67

Principles of x-ray formation ............................................................................................... 67
The quality of the radiograph .............................................................................................. 68
Factors controlling the x-ray beam...................................................................................... 69
Kilovoltage ....................................................................................................................... 69
Exposure time .................................................................................................................. 71
Milliamperage................................................................................................................... 71
Filter.................................................................................................................................. 72
Collimator......................................................................................................................... 72
Target-object distance...................................................................................................... 74
Basic principles of image formation.................................................................................... 74
Image sharpness .............................................................................................................. 74
Image magnification ........................................................................................................ 79
Image distortion............................................................................................................... 79
Intraoral radiographic techniques........................................................................................ 80
Bisecting angle technique ............................................................................................... 80
Paralleling technique ....................................................................................................... 83
Spatial localization: buccal object rule ................................................................................ 85
Radiographic orientation ...................................................................................................... 93
Endoral radiographic examinations ..................................................................................... 94
A) Preoperative or diagnostic radiographs.......................................................................... 94
Upper incisors.................................................................................................................. 95
Upper canine ................................................................................................................... 97
Upper premolars.............................................................................................................. 98
Upper molars ................................................................................................................... 99
Lower incisors .................................................................................................................. 100
Lower canine.................................................................................................................... 101
Lower premolars.............................................................................................................. 102
Lower molars ................................................................................................................... 103
B) Intraoperative radiographs .............................................................................................. 104
Upper incisors and canines............................................................................................. 104
Upper premolars.............................................................................................................. 104
Upper molars ................................................................................................................... 105
Lower incisors and canines ............................................................................................. 106
Lower premolars.............................................................................................................. 106
Lower molars ................................................................................................................... 106
Common causes of errors .................................................................................................... 110
XVIII

1) Light radiographs ............................................................................................................. 110

2) Dark radiographs ............................................................................................................. 110
3) Radiographs with poor contrast ...................................................................................... 111
4) Dark stains........................................................................................................................ 111
5) Light stains........................................................................................................................ 111
6) Yellow or brown stains.................................................................................................... 112
7) Blurry radiographs ........................................................................................................... 112
8) Radiographs with partial images ..................................................................................... 112
Protection of the patient, dentist, and auxiliary personnel ................................................ 115
Bibliography.......................................................................................................................... 118

CHAPTER 6 DIGITAL RADIOGRAPHY SYSTEMS (DRS) .......................................................................... 120

MARIO LENDINI

Origins and technological evolution ................................................................................... 120

Features of the DRS image................................................................................................... 123
Reading and processing of DRS images......................................................................... 124
Quality of DRS images .................................................................................................... 127
Hardware..................................................................................................................... 127
Acquisition Sensors..................................................................................................... 127
Software....................................................................................................................... 128
Execution and processing time............................................................................................ 129
Supplied dosage ................................................................................................................... 130
Adaptation and repetitiveness.............................................................................................. 131
Filing...................................................................................................................................... 132
Large formats ........................................................................................................................ 133
Bibliography.......................................................................................................................... 134

CHAPTER 7 PULPAL PATHOLOGY ............................................................................................................. 136

ARNALDO CASTELLUCCI

The reparative capacity of pulp tissue ................................................................................ 136

Pulpal diseases...................................................................................................................... 139
Clinical classification........................................................................................................ 139
Healthy pulp .................................................................................................................... 139
Hyperemia........................................................................................................................ 142
Clinical symptoms....................................................................................................... 142
Diagnosis..................................................................................................................... 143
Therapy ....................................................................................................................... 144
Pulpitis.............................................................................................................................. 144
Symptomatology ......................................................................................................... 144
Diagnosis..................................................................................................................... 144
Pulp tests ..................................................................................................................... 145
Radiographic examination.......................................................................................... 145
Therapy ....................................................................................................................... 147
Necrosis............................................................................................................................ 150
Symptomatology ......................................................................................................... 152
Radiographic examination.......................................................................................... 153
Pulp tests ..................................................................................................................... 153
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Therapy ....................................................................................................................... 153

Vital pulp therapy ................................................................................................................. 153
Pulp capping with MTA.............................................................................................. 155
Operative sequence for pulp capping....................................................................... 156
Bibliography.......................................................................................................................... 158

CHAPTER 8 PERIAPICAL DISEASE ............................................................................................................. 160

ARNALDO CASTELLUCCI, UZIEL BLUMENKRANZ

The reparative capacity of periapical tissues ...................................................................... 160

Classification of the lesionsof endodontic origin................................................................ 163
Chronic apical periodontitis ............................................................................................ 163
Granuloma and cyst ................................................................................................... 171
Granuloma .................................................................................................................. 172
Cysts ....................................................................................................................... 176
Reactivation of chronic apical periodontitis................................................................... 184
Acute apical periodontitis................................................................................................ 185
Acute alveolar abscess..................................................................................................... 185
The Cracked-Tooth Syndrome ............................................................................................. 191
Introduction ..................................................................................................................... 191
Definition ......................................................................................................................... 191
Cracked tooth syndrome ...................................................................................................... 191
Etiology ............................................................................................................................ 192
Symptoms......................................................................................................................... 194
Clinical findings ............................................................................................................... 196
Diagnosis.......................................................................................................................... 197
Classification .................................................................................................................... 199
Treatment ......................................................................................................................... 199
Class I ............................................................................................................................... 200
Class II.............................................................................................................................. 201
Class III............................................................................................................................. 201
Class IV............................................................................................................................. 203
Conclusion ....................................................................................................................... 203
Bibliography.......................................................................................................................... 204

CHAPTER 9 THE USE OF ANESTHESIA IN ENDODONTICS ....................................................................... 208

ARNALDO CASTELLUCCI, KIRK A. COURY

Topical anesthesia ................................................................................................................ 208

Local infiltration .................................................................................................................... 209
Regional anesthesia or nerve blocks ................................................................................... 210
Inferior alveolar nerve block........................................................................................... 210
Indirect technique....................................................................................................... 210
Direct technique ......................................................................................................... 210
Mental nerve block .......................................................................................................... 212
Nasopalatine nerve block................................................................................................ 213
Anterior palatine nerve block ......................................................................................... 213
Supplemental anesthetic techniques ................................................................................... 214
Anesthetic solutions and inflammation .......................................................................... 214
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Lingual infiltration............................................................................................................ 215

Intraseptal injection ......................................................................................................... 215
Intraligamental infiltration ............................................................................................... 216
Intrapulpal infiltration...................................................................................................... 218
Intraosseous anesthesia ........................................................................................................ 219
The intraosseous technique ............................................................................................ 219
Step 1: anesthetize the attached gingiva ................................................................... 219
Step 2: Cortical plate perforation ............................................................................... 220
Step 3: Injecting into the cancellous bone ................................................................ 221
Dosage reccomendations ................................................................................................ 222
Duration of anesthesia..................................................................................................... 222
Considerations for intraosseous anesthesia.................................................................... 222
Anatomical considerations ......................................................................................... 222
Patient considerations...................................................................................................... 223
Other considerations ....................................................................................................... 223
Bibliography.......................................................................................................................... 224

CHAPTER 10 TOOTH ISOLATION: THE RUBBER DAM ............................................................................... 226

ARNALDO CASTELLUCCI

Instruments ........................................................................................................................... 228

1) Rubber dam ................................................................................................................. 228
2) Rubber dam punches.................................................................................................. 228
3) Rubber dam clamps .................................................................................................... 228
4) Rubber dam clamp forceps ........................................................................................ 229
5) Rubber dam frame ...................................................................................................... 230
6) Lubricant ...................................................................................................................... 231
7) Rubber dam napkins................................................................................................... 231
8) Dental floss.................................................................................................................. 231
9) Assistant ....................................................................................................................... 231
Positioning of the dam ......................................................................................................... 231
Bibliography.......................................................................................................................... 243

CHAPTER 11 ACCESS CAVITY AND ENDODONTIC ANATOMY ................................................................... 244

ARNALDO CASTELLUCCI

Requirements of the access cavity ....................................................................................... 244

Rules for the preparation of an adequate access cavity ..................................................... 249
General principles for the preparation of the access cavity............................................... 250
Penetration phase ............................................................................................................ 250
Enlargement phase .......................................................................................................... 251
Finishing and flaring phase............................................................................................. 252
Upper central incisor ............................................................................................................ 253
Upper lateral incisor ............................................................................................................. 257
Upper canine ........................................................................................................................ 258
Upper first premolar ............................................................................................................. 259
Upper second premolar ....................................................................................................... 264
Upper first molar .................................................................................................................. 266
Upper second molar............................................................................................................. 277
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Upper third molar................................................................................................................. 279

Lower central incisor ............................................................................................................ 280
Lower lateral incisor ............................................................................................................. 284
Lower canine ........................................................................................................................ 285
Lower first premolar ............................................................................................................. 287
Lower second premolar ....................................................................................................... 289
Lower first molar................................................................................................................... 291
Lower second molar ............................................................................................................. 299
Lower third molar ................................................................................................................. 312
The access cavity in prosthetically prepared teeth ............................................................. 315
The access cavity through prosthetic crowns ..................................................................... 317
Common errors in the preparation of the access cavity .................................................... 319
Errors related to inadequate preparation ....................................................................... 319
Errors related to over-aggressive preparation ................................................................ 325
Bibliography.......................................................................................................................... 327

CHAPTER 12 PRETREATMENT: PREPARATION TECHNIQUES FOR ENDODONTIC THERAPHY .................... 330

STEFANO PATRONI, PAOLO FERRARI

Introduction .......................................................................................................................... 330

Pretreatment.......................................................................................................................... 331
Modern indications forendodontic pre-treatment.......................................................... 332
Classification ......................................................................................................................... 332
Periodontal pretreatment...................................................................................................... 334
Gingivectomy-gingivoplasty............................................................................................ 334
The apically repositioned flap ........................................................................................ 334
Prosthetic restorative pretreatment ...................................................................................... 335
Hollow posts .................................................................................................................... 336
Conservative restorative pretreatment ................................................................................. 339
Reconstruction of the fourth wall ................................................................................... 339
Copper and orthodontic bands....................................................................................... 339
Amalgam anchored with posts or amalgam pins .......................................................... 343
Pre-endodontic composite ......................................................................................... 344
Orthodontic pretreatment..................................................................................................... 347
Bibliography.......................................................................................................................... 351

INDEX ............................................................................................................................................... 352