Two Cases for Improving Irrigation During Root Canal Treatment
Root canal treatment is challenging enough. And when your patient’s canal is curved or presents with another demanding anatomy – shaping, cleaning, and filling increases the difficulty. You’re perhaps aware of advancements made in terms of flexibility and performance for root canal shaping Ni-Ti instruments. Regardless of the case’s hardship they’re proven effective for following tooth anatomy and removing pulp tissue and bacteria.
The noticeable zone of difficulty for root canal treatment
Studies have proven that the apical third zone holds the prize for treatment problems. The noteworthy challenge involved the goal of eradicating bacteria. Untreated areas (following instrumentation) ranged from 10% to 50%.  This highlights the importance of irrigation solutions for achieving successful therapeutic outcomes.
As a result, the irrigation tip market has targeted the safe and adequate delivery volume of irrigant as the standard for success. The goal: bring irrigant (safely and adequately by volume) as close as possible to the working length. Tests on several designs and materials provide you, as a clinician, the best in terms of cleaning effectiveness and ease of use.
Two cases where two different irrigation tips produced beneficial root canal treatment results
Case 1 – Painful chewing on lower right first molar
This endodontic treatment referral involved a 40 year old patient.
Pre-op x-ray revealed that the root canal lumen was visibly diminished.
The pulp chamber had been filled with flowable composite.
Clinical exam showed a large abraded composite restoration.
Placement of a rubber dam to isolate treatment field prior to beginning root canal therapy
Access cavity (ideally, the coronal projection of the root canals is meant to be as small as is practically possible) provided the correct shaping requirements in the root canal.
Coronal composite was carefully removed using a diamond-coated bur upon reaching the pulp chamber floor.
The access cavity was designed and previously placed carboxy cement within the root canals was removed.
Root canal openings were sought and discovered using an operative microscope. Subsequent cement removal was necessary due to the primary treatment not respecting the basic principles of shaping, cleaning, and filling (tridimensionally) the patient’s root canal system – and considering that pulp was still present in the canals.
A scouting phase followed using thin, stainless steel manual instruments and Ni-Ti rotary files. Ni-Ti reciprocating files were used to shape the root canal system.
Post root canal enlargement was followed with irrigation using 5% sodium hypochlorite via a 0.3mm stainless steel side-vented needle – keeping tip proximity as close as possible to working length.
Fluid was activated with sonic inserts (according to indications by Tonini et al). Root canals were dried with aspiration and paper cones.
Obturation phase utilized warm gutta-percha via the continuous wave technique.
Provisional obturation was placed and the patient returned to the referring dentist for the final indirect restoration.
Fig. 1 - 14 “IrriFlex. Case Report” by dr Grzegorz Witkowski
Case 2 – Intense pain on tooth 3.8
Treatment protocols were provided to a 56 year-old patient. 
Tooth revealed an extended decayed lesion.
X-rays confirmed that decay was in proximity to the pulp chamber.
Root canal treatment protocols
A lower alveolar nerve block was delivered, a rubber dam was placed, and decay was removed with assistance of a microscope.
Following decayed tissue removal the access cavity was conservatively completed and root canal openings were discovered and enlarged using ultrasonic tips.
Root canal scouting was executed with thin hand files followed by the shaping procedure using reciprocating Ni-Ti files.
Irrigation was performed with IrriFlex – a novel polypropylene irrigation tip with two side-vented exits. Irrigant activation was completed with sonic tips.
Shaping and irrigation were alternated until the root canals were observed to be clean and appropriately tapered.
Paper cones were used to dry the root canals and obturation (in this case) was completed with a single cone and bioceramic sealer.
The access cavity was sealed with composite material and the patient was scheduled for an indirect restoration.
Fig. 21 – 36 “IrriFlex. Case Report” by dr Grzegorz Witkowski
Treatment rationales and outcomes relative to each case’s root canal treatment
Of note, each clinical case was provided by the same experienced practitioner. And favorable outcomes were achieved on each.
How the specific case presented determined the choice made relative to clinical protocols. Differences in the use of irrigation tips and obturation methods were as follows according to the clinical documentation.
”If there were no difference in the shaping system selected (since the combination between manual scouting and reciprocating Ni-Ti files permitted to shape the root canals decreasing the risk of instrument fracture, even in presence of strong curvatures), the irrigation tip and the obturation method selected were different.”
Product availability and root canal anatomy determined the choice of irrigation tips used. Irrigation played a key role in both cases due to rationale associated with mechanical shaping such as the inability to remove all pulp remnants, smear layer, and bacteria.
Outcomes relative to case 1
Thin, metal, side-vented tip was used.
Root canals were straight – permitting good tip penetration delivering sodium hypochlorite into the root canal.
The presence of a lateral exit for the irrigant prevented the tip’s extrusion in the periodontium.
Outcomes relative to case 2
A metal tip (even if pre-bent) was not used where the curvature of the roots was more pronounced. This would not have permitted the irrigant to be close to the working length.
It was understood that metal needles tend to block towards the canal walls. This diminishes the volume of irrigant reaching the apex leading to less effective fluid dynamics.
Choice of irrigation tip leads to preferred results for root canal treatment
IrriFlex was the chosen soft body, polypropylene irrigation tip for Case 2.
Smoothly reached the working length without revealing any penetration problems within the root canal. This is possible due to the tip body’s capability to follow the shape of the root and allows high irrigant volume delivery to the apex.
Provided effortless needle positioning with respect to working length as a result of the presence of length marks on the body of the tip to guide the clinician.
Delivered the solution with equal efficiency because of the syringe plunger’s soft pressure irrigation capability.
The overall effectiveness of IrriFlex during this case was noted as follows:
”IrriFlex was effective and safe, because of the back-to-back two side vent design of the tip that prevented the irrigating solution from extruding into the periapical tissues and helped achieving clean canal walls (that appeared glossy when watched with the operative microscope) in a short time.” 
This article was based on the paper “IrriFlex. Case Report” by dr Grzegorz Witkowski. The original document (in English) is available on our e-Learning platfom.