Documentos de Académico
Documentos de Profesional
Documentos de Cultura
CONTENTS
Preface
Syngcuk Kim
Modern Endodontic Practice: Instruments and Techniques
Syngcuk Kim
xi
11
19
The advent of nonsurgical ultrasonic tips has opened up a new horizon in endodontic treatment. There are a number of nonsurgical
VOLUME 48
35
55
The introduction of nickeltitanium (NiTi) as material for endodontic instruments about 15 years ago opened many new perspectives.
Many dentists and scientists see a benefit in using NiTi files. Initial
problems such as frequent fractures and the uncertainty of the best
way to use them have been solved. Other challenges such as enhancing the cutting ability or optimizing the speed, torque, and fatigue are currently being addressed. Some clinicians are skeptical
because they see this approach as too mechanical. Nevertheless,
the combination of anatomic, biologic, and pathophysiologic
knowledge with the use of NiTi instruments is a large step forward
in optimizing the quality of root canal treatment worldwide.
69
CONTENTS
ProTaper NT System
Thomas Clauder and Michael A. Baumann
87
This article reviews the design and clinical use of the ProTaper NT
file system.
113
This article describes the use of an innovative, engine-driven, rotary, root canal preparation instrument. The geometric design of
this nickel-titanium instrument is totally different from currently
marketed manual or engine-driven stainless steel or nickeltitanium instruments. The thin, taperless, noncutting shafts of
LightSpeed instruments maximize the flexibility of the nickeltitanium alloy, particularly in the larger sizes. The three basic designs of the LightSpeed cutting heads and three different methods
for using the LightSpeed system are described. LightSpeed instruments enable larger apical preparations in curved canals with less
coronal flaring than is possible with most other techniques.
137
The K3 rotary nickel-titanium file system by SybronEndo is a stateof-the-art rotary nickeltitanium endodontic instrumentation
method that combines excellent cutting characteristics with a robust sense of tactile control and excellent fracture resistance. The
K3 has universal applicability across a wide range of clinical indications. Although it is a complete instrumentation system, future
possibilities for hybrid instrumentation techniques that combine
the best features of K3 with other rotary systems hold promise.
159
183
The idea of the hybrid concept is to combine instruments of different file systems and use different instrumentation techniques to
CONTENTS
vii
manage individual clinical situations to achieve the best biomechanical cleaning and shaping results and the least procedural errors.
The hybrid concept combines the best features of different systems
for safe, quick, and predictable results. Several hybrid instrumentation sequences are presented and their limitations are discussed.
203
With all the new technology that has been introduced in endodontics, there are now several ways to instrument and obturate root
canals. Practitioners often develop their own hybrid technique
after sharing ideas with several colleagues. The purpose of this
article is to describe a technique of obturation, hoping that others
may incorporate some aspects into their own hybrid style.
217
265
Technologic advancements in dentistry and specifically endodontics have vastly improved the quality of care rendered to patients.
These advancements allow clinicians to gain insight into the retreatment of failing root canals. Due to training, practice, and patience, clinicians can expand their capabilities alongside of these
technologic advancements to perform endodontic retreatments
with increased success.
291
viii
CONTENTS
309
323
Root canal morphology is a critically important part of conventional and surgical endodontics (root canal therapy). Many in vitro
studies have recorded the scales and average sizes of root canals,
but there have been few clinical attempts to determine the working
width. In the absence of a study that defines what the original
width and optimally prepared horizontal dimensions of canals
are, clinicians are making treatment decisions without any support
of scientific evidence. This article provides definitions and perspectives on the current concepts and techniques to handle working
widththe horizontal dimension of the root canal systemand
its clinical implications.
Index
CONTENTS
337
ix
Preface
xii
The specialty of endodontics has evolved and changed over the years like
many other dental and medical specialties. The changes that have occurred
in the last 10 years, however, have been of great magnitude and profundity.
The microscope, ultrasonic units with specially congured tips, superbly
accurate microchip computerized apex locators, exible nickel-titanium les
in rotary engines, and greater emphasis on microscopic endodontic surgery
have totally changed the way endodontics and endodontic surgery are
practiced. Comparing these changes with formocreosol medication, K-le
and radiographic determination of working length are truly dramatic. These
changes are bringing the specialty of endodontic practice into the twentyrst century with greater precision, fewer procedural errors, less discomfort
to the patient, and faster case completions.
Seven key advancements in endodontics were made in the last decade. Indepth discussion of each of these advancements is found in articles elsewhere
in this issue. In this article, the advancements and their applicability to
everyday practice are discussed (Fig. 1).
The microscope
The previous issue of the Dental Clinics of North America was devoted to
the use and advantages of the microscope. Briey, the microscope provides
great magnication and illumination and functions as an extension of loupes
(Fig. 2). The proper use of the microscope in endodontic therapy provides
an advantage over any other tools. The question of why we need loupes
or microscopes can be answered quite simply: loupes provide 2 to 4
magnication. Although small, this magnication has such an impact that
E-mail address: syngcuk@pobox.upenn.edu
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.002
Fig. 1. Key instruments for the modern practice. (A) Electronic apex locator. (B) Nickeltitanium rotary ProFiles. (C) System B. (D) Spartan Piezo ultrasonic instrument. (E ) Obtura II.
Fig. 2. The bright focused light and high magnication provided by the microscope results in
endodontics of the highest, most accomplished level.
Fig. 3. A completely instrumented madibular rst molar at 4 magnication (A). The same
tooth at 24 magnication (B) that shows dentin covering the pulpal oor. After removal of the
dentin, another canal is located and instrumented (C).
anyone who is used to loupes cannot practice without them. The microscope
provides 4 to 25 magnication. The questions here are, Do we need
magnication that great? and, in extension, What is the optimum
magnication for endodontic procedures? In the authors opinion, the optimum magnication for endodontic practice ranges from 8 to 24 magnication (Fig. 3). The high magnication is needed to locate hidden canals,
detect microfractures, distinguish between the chamber oor and dentin, and
identify isthmuses and other small anatomic entities, of which recognition
and treatment are so important for endodontic therapy success.
In conventional endodontics, the microscope is most useful for locating
canals after the access is made. It is extremely useful for post removal using
ultrasonic instruments and for perforation repair. These are procedures that
previously were done largely by feel. The advent of the microscope in
modern endodontic therapy facilitates a primarily visually guided, secondarily sensory-aided endodontic procedure (Fig. 4).
Ultrasonic instruments
There are two types of ultrasonic tips on the market: surgical and
nonsurgical.
Surgical tips are for root canal retropreparation, and there are many types
available (see the Obtura/Spartan Company Web site, Fenton, Misssouri).
Nonsurgical tips come in two categories. First, the Buc tip is used for
conventional cases such as cleaning the chamber so that endodontists can
visualize the chamber without dentin debris (see the article by Kim elsewhere
Fig. 4. The microscope is best used for repair of perforation (A), identication or detection of
microfractures (B), and removal of posts and/or separated les (C).
in this issue, [Fig. 8]). The sharp-ended tips allow clinicians to pick and
explore the chamber oor to identify canals. This ultrasonic instrument is
a lifesaver when calcied canals are encountered. High- or low-speed burs are
much too large to catch the minute, sometimes microscopic, openings to
calcied canals. A second type of nonsurgical ultrasonic tip is the CPR tip.
These tips are used mainly for post removal. Although posts can be removed
with burs, even the smallest burs unnecessarily remove large amounts of
dentin compared with CPR tips. Over 90% of the post can be removed by
CPR tips driven by a Piezo ultrasonic instrument, with much less gouging or
damaging the dentin structure around the post than with burs.
Cleaning the pulp chamber is also an important prerequisite for inspection
of the chamber for anatomic details. This cleaning can be done best with
a diamond-coated small microburner tip (eg, Buc tip size 2). Microscopic
observation is not eective when the chamber oor is full of dentin debris
that is created by burs.
correctly. This precision is needed to minimize intervisit are-ups, overllings, and underllings. In the authors department, postgraduate students
rely more on their apex locators than on radiographs. This practice has
contributed greatly to pain-free treatments without are-ups and with longterm healing successalmost impossible 10 years ago.
System B or Touchn Heat
In the old daysonly 10 years agoa torch or open ame was used to
sear or melt the gutta percha. This technique is now called Flintstone-age
endodontics. The System B and Touchn Heat (SybronEndo, Orange,
California) allow a safer means to heat the gutta percha (see Fig. 1C).
Specially designed tips of varying sizes are connected to the System B and
are heated instantly to the desired temperature by touching a sensor on the
handle. A tip is inserted into the obturated canal, the sensor to heat the tip is
activated, and the gutta percha is thermoplastesized. This thermoplastesized
gutta percha is then condensed (eg, with S-Kondensers) to obturate the
canal. It has been shown that the resulting temperature elevations within the
canal do not damage the periodontal ligament. The obturation technique
using System B is gaining popularity among endodontists and is gradually
replacing the old technique.
Obtura compactor
The Obtura compactor is another innovation in modern endodontic
practice that has become a must have. Thermoplastesized gutta percha
was used in endodontics before the invention of this compactor; however,
the procedure was done in the canal using hot instruments. With the advent
of this instrument, gutta percha is thermoplastesized in a specially designed
gun that is connected to an electronically controlled unit (see Fig. 1E).
Varying tip sizes determine the depth of penetration (ie, the thinner the tip,
the deeper the penetration). In this manner, the canal is more homogeneously and densely lled. The use of the compactor is especially useful
when dealing with internally resorbed canals that cannot properly be lled,
even with the lateral condensation technique.
Nickeltitanium les
The nickeltitanium (NiTi) revolution took place in the mid-1990s. Now
there are numerous NiTi rotary le systems available (see Fig. 1B). At
the time of this writing, there are over 20 dierent types of NiTi rotary
le systems available, with new ones being introduced every year. This
development is similar to the titanium implant development some years ago.
In 1980, there was only one system; now there are so many. One salient
question is, Will NiTi le systems replace the stainless steel K-le system?
The answer is denitely not. The NiTi le systems are very convenient for
milling the canal but not for cutting the canal dentin. Cutting the dentin is
usually done with GatesGlidden burs or K les in combination with NiTi
rotary les. By using these instruments, the canals can be prepared more
easily and uniformly. Some clinicians avoid the NiTi rotary systems due to
breakage of the le tip inside of the canal. This breakage can be minimized
greatly by light-handed and careful use. The author considers the NiTi le
system not a must-have instrument, but rather a convenient instrument.
There are basically two types of NiTi systems: the LightSpeed (LightSpeed, San Antonio, Texas) and the non-LightSpeed types. The LightSpeed
type is a miniaturization of the GatesGlidden bur, with a 0.02-type handle
with varying le tip diameters. The non-LightSpeed types include active
systems with a positive rake angle that cut the dentin, and others that are
passive with a negative rake angle that mill the dentin. For instance, the
most popular type is the ProFile (Dentsply, Tulsa, Oklahoma) with a
negative rake angle. Each of these systems oers les ranging from 0.02 to
0.12 taper with smaller tip diameters.
Although there are many pitfalls on the road to consistent results, with
proper use of the NiTi systems, endodontists will be able to improve the
quality and esthetics of their endodontic obturations quickly.
Mineral trioxide aggregate
Mineral trioxide aggregate (MTA) is a reliable new endodontic material
initially designed as a retrolling material. More recently, it also has been
advocated for pulp capping, perforation repair, and even as an endodontic
lling material for apexication. MTA is a mixture of many oxides and looks
like grayish-brown sand. In fact, it handles like sand and some clinicians have
compared it to Portland Cement. In a moist environment, it sets in about 7
hours. In conventional endodontics, it has proved to be the best material for
most types of perforation. Its unique physical property is its compatibility
with bone. It has been shown in numerous studies and in clinical practice that
it is the only material into which bone and cementum cells actually grow,
thereby creating a perfect seal and an ideal barrier. This is a material that has
long been on the endodontic wish list because perforations during endodontic procedures or during post preparation are not that uncommon.
Fig. 5. At high magnication, a fourth canal (MB2) of a maxillary rst molar can easily be
detected (A) and is shown with a size 10 le in the canal entrance (B). (Courtesy of F. Maggiore,
DDS, Rome, Italy.)
Fig. 6. Radiograph of the maxillary rst molar prior to endodontic therapy (A) and microscopic examination of the prepared four canals at 24 magnication of the same tooth (B).
11. This master cone, coated with root canal cement, is inserted into the
canal, and the coronal part of the point is seared o using System B. The
gutta percha in the apical 3 to 4 mm is packed with S-Kondensers.
12. The Obtura gutta percha compactor with an appropriate tip is inserted
into the canal up to where the master gutta percha was seared o. The
thermoplastesized gutta percha lls the canal as the tip is slowly
withdrawn.
13. The microsocpe is used again for a nal check. Finally, the canal is
sealed with temporary cement.
This brief sequence shows the use of modern endodontic instruments.
The purpose of incorporating these advanced instruments is to perform
endodontic procedures more accurately, thus experiencing less postoperative discomfort, fewer procedural errors, and a more ecient procedure.
Although the ultimate criteria (ie, whether the incorporation of these
instruments provides greater treatment results and success) has still not been
established in a formal study, the authors clinical experience of the last 10
years has shown that the procedures are more predictable, ecient, and
reliable, and result in fewer are-ups and less discomfort for patients. In
addition, the radiographic results are far better, with a signicant increase of
over 40% in locating fourth canals in molars (Fig. 7). These improvements
are truly signicant.
12
dam, then the mirror would fog immediately from the exhalation of the
patient. Thus, the powerful microscope magnication and illumination would
be rendered totally useless for the necessary visualization of the chamber oor
and the canal anatomy. To absorb reected bright light and to accentuate the
tooth structure, it is recommended to use blue or green rubber dams (Fig. 2).
Fig. 2. The use of a rubber dam is essential for eective microscope use.
13
Fig. 3. Patients should wear protective dark glasses and have support for the neck, such as
a moldable pillow.
14
Fig. 4. Positioning the microscope. Notice the ergonomics of the clinician and comfortable
patient position.
a le can be challenging because there is only a tiny space between the mirror
and the tooth for a nger with a le to move around. Files specially designed
by Maileer, called microopeners, have with dierent sized tips and can be
extremely useful (Fig. 5). These hand-held les allow the clinician to initially
negotiate the canal, verifying that the catch is truly a canal. After the canal
is located in this manner, clinicians can instrument the canal normally without
the microscope. The use of GatesGlidden burs to enlarge the canal entrance
prior to full instrumentation, however, can be easily achieved under the
microscope, facilitating the subsequent steps of canal instrumentation.
Fig. 5. Micro-openers by Maillefer are ideal instruments for exploration of hidden canals at
high magnication.
15
Fig. 6. Microfracture detected under the microscope (A) and the same tooth after extraction
(B). Arrows identify the fracture line.
16
Fig. 7. Buc tips (Obtura/Spartan) are ideal ultrasonic instruments for cleaning the pulp
chamber and oor for clear viewing of the canals.
17
Fig. 8. Access preparation and management of calcied canals at a high magnication under
the microscope (AF ). (Courtesy of F. Maggiore, DDS, Rome, Italy)
18
Nonsurgical ultrasonic
endodontic instruments
Mian K. Iqbal, BDS, DMD, MS
Department of Endodontics, The Robert Schattner Center, University of Pennsylvania,
School of Dental Medicine, 240 South 40th Street, Philadelphia, PA 19104-6030, USA
One of the most important advancements in endodontics has been the use
of the surgical operating microscope, which in turn necessitated the
evolution of a number of microendodontic instruments. Among these,
ultrasonic instruments have improved the most. Ultrasonic technology has
been available for a long time [1]; the only thing needed to make a modernday ultrasonic instrument was incorporation of a contra-angle bend and
parallel working ends. The contra-angle design allowed for dramatic
improvement in procedural access for both anterior and posterior teeth,
in addition to an unobtrusive view under the microscope.
Ultrasonic instruments play an ever-increasing role in several aspects of
endodontic treatment. Teeth with root canal obstructions are no longer automatically treatment planned for surgical endodontics; endodontic retreatment has become the procedure of choice. In addition, root canal obstructions
are being removed in a more conservative manner that does not unnecessarily
destroy the root structure. The identication of missed and hidden canals has
become a predictable outcome rather than a serendipitous discovery. Access
cavities are being cut and rened with greater precision, opening up gateways
to better endodontics. Above all, these procedures are no longer being
performed blindly; instead the clinician is now able to maintain visual contact
with the operating eld at all times during ultrasonic procedures.
The ultrasonic technique is essentially a nonrotary method of cutting
dental hard tissue and restorative materials using piezo-electric oscillations.
Cutting dentine structure with ultrasonic tips is analogous to cutting dentine
with the thinnest bur imaginable. Because the operating eld is so restricted,
the use of high magnication and proper illumination is essential during the
use of these instruments. The combination of ultrasonic instruments with the
20
21
Fig. 1. Two tips from the Osada Enac ultrasonic endodontic system. The ST21, shown at the top,
is used for removing solids from root canals. The bottom picture shows the vibratory tip ST09.
Fig. 2. Retreatment CPR tips 2D through 5D are diamond coated with built-in water ports that
allow for wet or dry cutting.
22
23
and depth of dentine cut with an increase in power setting. However, the
slender and longer tips with small cross-sectional diameters (ie, CPR 68) will
fracture easily when used at high intensity. On the other hand, short and
sturdy tips used for vibrating posts out of root canals are operated at
medium-high intensity. Similarly, tips that are used for bulk removal of
dentine or restorative materials (eg, CPR 2) also need to be used at moderate
to high intensities. The troughing tips (eg, CPR 3D5D, BUC 3, and CPR 6
8) should be used at low intensity. In general, thick and short tips are
operated at higher intensities, whereas long and slender tips are operated at
lower intensities.
Tips with bends increase access to dierent parts of the mouth; however,
excessive angulations also make these tips more vulnerable to breakage [3].
In addition, tips that are designed primarily for cutting dentine can break
24
25
action can be observed directly and continuously under the microscope. The
size of ultrasonic tips is smaller than the smallest burs; therefore, the dentine
can be brushed o in smaller increments and with greater control. The
process allows for exposure of any missed or hidden canals or recesses
containing necrotic pulp tissue without gutting down the tooth structure
(Fig. 6). The process is similar to archeologists unearthing artifacts at
excavation sites. The dentine must be brushed o in smaller increments until
the road map on the oor of the pulp chamber is uncovered completely. The
usual term used for this procedure is unroong the pulp chamber;
however, this term is valid only when dealing with young and large pulp
chambers. For pulp chambers that have receded with calcication, the term
uncovering the oor of the pulp chamber is more appropriate.
Another advantage of ultrasonic instruments over burs is the production of
cavitation within the cooling water that ows over the tip of the ultrasonic
instrument [4]. Cavitation may be described simply as bubble activity in
a liquid, which is capable of generating enough shock waves to cause
disruption of remnants of necrotic pulp tissue and any calcic deposits.
Therefore, it is no wonder that access cavities prepared with ultrasonic
instruments have a thoroughly washed out and clean appearance (see Fig. 6B).
A number of tips are available to rene the access cavity. The uncovering of the oor of the pulp chamber can be accomplished with the help of
the CPR 2D or BUC 1 tips. If the dark, colored oor of the pulp chamber is
not visible, it usually is obscured by pulp stones or tertiary dentine deposits
(Fig. 7). The pulp stones sometimes can be vibrated or teased out by the
CPR 2D or BUC 1 tips (see Fig. 7A); at other times, they can be planed with
the help of a BUC 2 tipa process similar to planing the root surface. The
tip of this instrument is designed with a planed surface and it can grind the
oor until the dark-colored dentine becomes visible. The unveiling of
the dark-colored oor of the pulp chamber is of critical importance because
it dictates and guides the extension of access cavity.
Fig. 6. (A) Mandibular molar requiring retreatment shows presence of gutta-percha in two
mesial and one distal canal. The remaining chamber contained remnants of sealer cement and
necrotic tissue. (B) Removal of gutta-percha lling and use of ultrasonic instruments exhibits
debridement of the chamber and the presence of an untreated fourth distal canal.
26
Fig. 7. (A) An ultrasonic tip is being used to remove heavy calcic deposits on the oor of
a maxillary molar pulp chamber. (B) The use of ultrasonic energy led to shattering of pulp
stone. (C) This picture reveals the presence of four root canal orices, but the absence of any
pulpal oor road map. (D) Continued removal of calcication and renement of access cavity
with ultrasonic instruments exposes the oor of the pulp chamber and the presence of an
additional distobuccal canal. (Courtesy of Dr. Helmut Walsch, Munich, Germany.)
27
root trunk only. To check progress, an ultrasonic tip is used to dig a test
hole at the most probable site of the sclerosed canal. The test site is lled
with thermoplastisized gutta-percha and an orientation radiograph is
exposed (Fig. 8). If the test site is found centered in the root and pointing
correctly, then cutting is continued to enter the canal; otherwise, the
direction of the cutting is modied according to information gathered from
the radiograph. Radiographs are two dimensional in nature, however, and
do not provide any information regarding the bucco-lingual depth of the
tooth structure.
Vibratory tips
Removal of intraradicular posts has always been a challenge when
performing endodontic retreatment. This procedure also has been fraught
with unwanted consequences, such as root fracture or perforation. The
implementation of ultrasonic energy has provided the clinician with an important adjunctive method for removal of posts. A number of studies [811]
have shown conclusively that the use of ultrasonic vibration signicantly
reduces the amount of tensile force required to dislodge both the cast and
prefabricated posts. The VT (Sybron Endo), Osada Enac ST09, and CPR 1
are examples of such instrument tips. The tips of these instruments are
spherical or at and are placed against the post to transmit vibration. They
Fig. 8. A check radiograph of a calcied central incisor showing an ultrasonically prepared test
site lled with radiopaque gutta-percha. The ultrasonic tip was not aligned parallel to the long
axis of the tooth and needed to be redirected to avoid root perforation.
28
Troughing tips
Troughing tips are used to create a suciently deep trough around posts
to maximize the benets of subsequently applied vibratory or extraction
forces. In the past, troughing around the root canal obstruction was performed with trephine drills. This process was extremely destructive and frequently led to the gutting down and perforation of root trunks. Now with
the help of ultrasonic tips, troughing around root canal obstructions can be
performed in a predictable and controlled manner.
29
Fig. 9. The initial troughing around a post can be performed with shorter tips such as diamondcoated CPR 2D or 3D. (Courtesy of Dr. Samuel Kratchman, Exton, PA.)
Fig. 10. (A) CPR 6 is being used to trough between the post and the lingual wall of the root
canal. (B) View of the trough produced around the lingual aspect of the post with the help of
ultrasonic les.
30
Fig. 11. (A) Radiograph showing the presence of a long, threaded post associated with a failing
root canal treatment. (B) Radiograph showing completion of root canal treatment after
removal of the threaded post.
31
Fig. 12. Drawing showing LightSpeed instruments attened at their tips with the help of
a grinding stone.
32
Fig. 13. (A) Initially, a small-sized instrument is selected and carried down to the obstruction.
(B) Instruments are used sequentially to enlarge the root canal space. The arrow in the gure
points toward the approximation of a modied LightSpeed instrument and the root canal
obstruction. (C) The arrow in the gure points toward a shelf of dentine that has been created
around the separated instrument. (D ) The arrow indicates a trough created around the
separated instrument with the help of ultrasonic tips.
33
Fig. 14. (A) Preoperative radiograph of a maxillary left rst premolar shows a separated
instrument in the palatal canal. (B) Postobturation radiograph. The instrument was removed
easily with ultrasonic vibration. (Courtesy of Dr. Bekir Karabucak, Philadelphia, PA.)
from the surrounding root canal dentine. Under the microscope, the
pastedepending on its colorappears as a white or pinkish dot. The CPR
tips are used to eliminate it by following the dot to its apical extent.
However, no attempt should be made to remove paste materials around
curves, because the ultrasonic les are unable to negotiate curvatures and
may lead to perforation of the root surface. Ultrasonic tips also can be used
to help MTA ow precisely into place. This is done by depositing mineral
Fig. 15. (A) Drawing of a NiTi instrument depicting unwinding of the utes associated with
a torsional failure. (B) In case of exure failure, no signs of unwinding of the utes can be noticed.
34
Summary
The use of ultrasonic instruments has revolutionized the art of
endodontic retreatment. These instruments have multiple uses and have
become an integral part of the endodontic armamentarium. However, the
use of ultrasonic instruments requires specialized knowledge and development of certain skills that may require training before use.
References
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[2] Waplington M, Lumley PJ, Blunt L. An in vitro investigation into the cutting action
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[3] Walmsley AD, Lumley PJ, Johnson WT, Walton RE. Breakage of ultrasonic root-end
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[4] Roy RA, Ahmed M, Crum LA. Physical mechanisms governing the hydrodynamic
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[6] Weller RN, Hartwell GR. The impact of improved access and searching techniques on
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[7] Instructions for use. BUCTM non-surgical ultrasonic endodontic instruments. Fenton
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Accessed on January 21, 2004.
[8] Buoncristiani J, Seto BG, Caputo AA. Evaluation of ultrasonic and sonic instruments for
intraradicular post removal. J Endod 1994;20:4869.
[9] Berbert A, Filho MT, Ueno AH, Bramante CM, Ishikiriama A. The inuence of
ultrasound in removing intraradicular posts. Int Endod J 1995;28:1002.
[10] Johnson WT, Leary JM, Boyer DB. Eect of ultrasonic vibration on post removal in
extracted human premolar teeth. J Endod 1996;22:4878.
[11] Yoshida T, Shunji G, Tomomi I, Shibata T, Sekine I. An experimental study of the removal
of cemented dowel-retained cast cores by ultrasonic vibration. J Endod 1997;23:23941.
[12] Bergeron BE, Murchison DF, Schindler WG, Walker WA. Eect of ultrasonic vibration
and various sealer and cement combinations on titanium post removal. J Endod 2001;27(1):
137.
[13] Ruddle CJ. Micro-endodontic nonsurgical retreatment. Dent Clin North Am 1997;41(3):
42954.
[14] Ruddle C. Microendodontics. Eliminating intracanal obstructions. Oral Health 1997;87(8):
1921, 234.
[15] Sattapan B, Nervo GJ, Palamara JE, Messer HH. Defects in rotary nickel-titanium les
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[16] Jeng HW, ElDeeb ME. Removal of hard paste llings from the root canal by ultrasonic
instrumentation. J Endod 1987;13(6):2958.
* Corresponding author.
E-mail address: sjlee@yumc.yonsei.ac.kr (S-J. Lee).
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.10.005
36
were reported to be an accurate and reproducible method as the newest thirdgeneration type and can acknowledge a root perforation. However, some
questions still exist as to whether the accuracy of EAL can be aected by the
dierent types of electrolytes [19,43,45], the types of electronic working
mechanism, and the conditions of the root canal, such as pulp vitality
[20,31,34], or foramen size [51,52]. This article reviews the history and the
working mechanism of the currently available EALs, and suggests the correct
use of an apex locator for a better canal length measurement.
History of EALs
Traditional-type apex locators (resistance or impedance type)
In 1918, Cluster [6] rst put forth the idea that the root canal length could
be determined by using the electrical conductance. Little was done with this
idea until 1942 when Suzuki [7] reported a device that measured the
electrical resistance between the periodontal ligament and the oral mucosa.
He discovered that in dogs, the electrical resistance between the root canal
instrument inserted into a root canal and an electrode applied to the oral
mucous membrane registered a consistent value of approximately 6.5 Kx.
These principles were not examined further until Sunada [8] performed
a series of experiments on patients and reported that the electrical resistance
between the mucous membrane and the periodontium was consistent,
regardless of the age of the patients or the shape and type of the teeth. In
1987, Huang [9] reported that this principle is not a biologic characteristic,
but rather a physical principle.
Inoue [10] reported a modication that incorporated the use of an
audiometric component that permitted the device to relate the canal depths
to the operator via low-frequency audible sounds. One of the most widely
used apex locators in the 1970s and 1980s, the Sono-Explorer (Union
Broach, New York, New York), was developed using this modication. By
1975, newer units such as the Neosono (Amadent, Cherry Hill, New Jersey)
and many other resistance-type apex locators became available. They have
improved circuitry, are more compact, and are easier to operate [11].
However, these resistance-type EALs often yield inaccurate results when
electrolytes, excessive moisture, vital pulp tissue, exudates, or excessive
hemorrhage are present in the canals [1214]. (The eect of the canal
contents on the accuracy of an EAL is discussed later in this article.)
A new apex locator, the impedance type, was developed in the late 1980s to
improve the resistance-type apex locators. The impedance-type EAL uses the
electronic mechanism that the highest impedance is at the apical constricture,
which is the narrowest portion of the canal where the impedance changes
drastically, when a canal is thought of as being a long hollow tube [15].
However, a question also was raised as to whether this mechanism could be
applied to the real root canal with various anatomical complications [16].
37
38
39
40
Table 1
Accuracy of frequency-dependent apex locators
Year
Study type
EAL
N (canals)
Comparison
Frank et al [32]
Mayeda [31]
Felippe and Soares [52]
Arora and Gulabivala [20]
Czerw et al [41]
Pratten and McDonald [33]
Lauper et al [30]
Shabahang et al [23]
Vajrabhaya and Tepmongkol [24]
Ounsi [59]
Dunlap et al [50]
Pagavino et al [25]
Ibarrola et al [58]
Ounsi and Naaman [49]
Lee et al [47]
Meares and Steiman [42]
Neekoofar et al [57]
Pommer et al [34]
Kielbassa et al [40]
1993
1993
1994
1995
1995
1996
1996
1996
1997
1998
1998
1998
1999
1999
2002
2002
2002
2002
2003
Patientradiograph
Patientextract
Extracted teeth
Patientextract
Extracted teeth
Cadaverextract
Patientextract
Patientextract
Patientextract
Extracted teeth
Patientextract
Patientextract
Extracted teethb
Extracted teeth
Patientextract
Extracted teeth
Extracted teethc
Patientradiograph
Patientextracte
Endex
Endex
Endex
Endex
Root ZX
Endex
Apit
Root ZX
Root ZX
Endex
Root ZX
Root ZX
Root ZX
Root ZX
Newly designed
Root ZX
Neosono Ultima EZ
AFA apex nder
Root ZX
185
33
350
61
30
27
30
26
20
34
34
29
16
36
31
40
54
152
105
Radiographic apex
Apical foramenM
Apical foramenD
Apical foramenM
Apical foramenD apical
ConstrictionM
Apical foramenM
Apical foramenM
Apical foramenM
Apical foramenD apical
ConstrictionM
Apical foramenSEM
Apical constrictionM
Major diameterD
CDJM
Apical foramenD
Apical foramenD
Radiographic apex
Minor diameterD
Accuracya
89.6%
87.9%
96.5%
71.7%
100%
89%
93%
96.2%
100%
84.56%
82.3%
82.75%
87.5%
84.72
92%
83%
94.4%
85.5%d
64.8%f
Reference
41
radiographic length. The recently marketed AFA Apex Finder [34] also
showed a high accuracy in clinical situations. When compared with
radiographic measurements, in 86% of the roots evaluated, the le tip
position (as indicated by the Apex Finder) was located within 0.5 mm of
a point 1.0 mm short of the radiographic apex.
In vitro studies
Felippe and Soares [52] tested the Apit in an isotonic saline container
model and found that 96.5% of 350 human teeth located the apical foramen
at a 0.5-mm clinical tolerance. Brunton et al [35] performed an in vitro
experiment to determine whether the use of an EAL (Analytic AFA) could
reduce radiograph exposure. In the group that did not use the EAL (25
teeth), 14 retake radiographs were required to determine the working length,
whereas in the group that used the EAL, no retake radiographs were
required. The EAL was extremely accurate in locating the apical foramen
with all the teeth tested within a 0.5-mm clinical tolerance. In contrast, only 15 (60%) teeth tested using radiographs alone were within the
0.5-mm clinical tolerance of the anatomic apex. El Ayouti et al [36] reported that the electronic working length measured by the Root ZX reduced
the percentage of overestimation to 21% compared with radiograph only.
Recently, the Bingo 1020 was introduced to dental practice. Kaufman
et al [37] compared this new frequency-dependent EAL with the Root ZX
and found that the Bingo 1020 was consistently more accurate than was the
Root ZX, although both units measured the tooth length with great
accuracy.
Digital radiography was compared with the Apit EM-S3 in a wellcontrolled in vitro model [38]. The electronic method was satisfactory in
67.8% of cases with a 0.5-mm clinical tolerance, versus 50.6% and 61.4%
for the conventional and digital radiologic methods, respectively. The
authors [38] concluded that none of the techniques were totally satisfactory
in establishing the true working length.
The 0.5-mm clinical tolerance is considered to be the strictest acceptable
range. Therefore, measurements attained within this tolerance were
considered to be highly accurate. However, some authors [39,40] prefer
the 1-mm range. Shabahang et al [23] reported that because root canals
frequently lack a well-delineated apical constriction, an error tolerance of
1 mm can be deemed clinically acceptable.
Accuracy of frequency-dependent EALs in dierent electrolytes
A major advantage of frequency-dependent EALs is that they operate
even with a high electroconducting irrigant such as sodium hypochlorite.
The operation is based on the principle of the relative dierence or a quotient
of two or more impedances generated at each dierent frequency. Although
42
43
Phoenix, Arizona). The results showed that the Root ZX reliably measured
the canal lengths to within 0.31 mm, regardless of the irrigants. However,
the largest deviation from the actual canal length was obtained with NaOCl.
The authors [43] stated that considering the widespread utility of NaOCl as
an intracanal irrigant, the increased variance of this irrigant should be
considered.
Pilot and Pitts [44] conducted a sophisticated study on the prediction
error of the EAL (Sono Explorer Mark IV, Union Broach). They evaluated
the impedance change at dierent locations in the root canal system with
various frequencies and canal irrigants and calculated the prediction error
when the EAL was used in these various conditions in vivo. No signicant
dierence was noted in the prediction error at dierent frequencies
(P > 0.05). However, the prediction error was signicant with respect to
the dierent irrigants (RC Prep, 70% isopropyl alcohol, 14.45% EDTA
sodium solution, normal saline, and 5.25% NaOCl) (P \ 0.02). A higher
prediction error was apparent for the more conductive solutions, such as
NaOCl. These results suggest that although the working mechanism is
unclear, the dierent electroconductivities somehow aect the EAL
measurement. When the electrical resistance of the most frequently used
irrigants were measured, NaOCl was much higher (10 times), whereas H2O2
was much lower (50 times), than saline [28]. It was speculated that the
change in the electroconductivity shifts the quotient curve of the frequency
ratio.
Kim et al [45] reported that there were tendencies toward a short
measurement in a high electroconductive solution such as NaOCl, whereas
longer measurements were in the lower electroconductive solution. These
tendencies were expressed by a voltage dierence. To minimize the measurement errors, they developed a new circuit that could automatically
compensate for the voltage dierences in the dierent irrigating solutions.
As a result of this compensation, the errors were signicantly reduced, on
average from 0.54 mm to 0.18 mm in the H2O2 solution and from 0.33 mm
to 0.01 mm in the NaOCl solution in an in vitro study. The accuracies
based on a 0.5-mm clinical tolerance were improved for the H2O2 and
NaOCl solutions from 71.1% to 91.1% and from 82.2% to 100%,
respectively. Briey, the impedance ratios and voltage dierences were
obtained from the three dierent irrigating solutions (saline, NaOCl, and
H2O2) in an extracted tooth model, using the conventional impedance ratio
method with two sinusoidal waves (0.5 and 10 kHz). From a total of 45 root
canals examined in each solution, the distributions of the voltage dierences
and the measurement errors were obtained. The voltage dierences
measured were generally larger in H2O2 and smaller in NaOCl when
compared with saline. The measured lengths were generally longer in H2O2
and shorter in NaOCl compared with saline. The impedance ratio of the two
dierent frequencies represented the position of the le, whereas the voltage
dierence represented the status of the uid in the root canal. Each irrigant
44
Fig. 1. Distributions of voltage dierence versus error for the three solutions in the canal. LL
and UL are decision boundaries that classify a smaller voltage dierence solution (NaOCl)
and a larger voltage dierence solution (H2O2) for 45 extracted root canals (in vitro).
was classied statistically using a Bayes linear classier (Fig. 1). The
compensating value was determined in proportion to the dierence between
the measured voltage dierence and either the upper limit (UL) or lower
limit (LL), which then was added or subtracted to the impedance ratio for
compensation. Therefore, during the actual determination of the working
length, the le would go deeper in a higher electroconductive condition such
as NaOCl, whereas it would go less deep in a lower electroconductive
condition such as H2O2.
When this compensation circuit was tested in clinical situations, Nam
et al [46] reported that the mean error was 0.14 0.27 mm from the
constriction point, and 95.2% of the measurements were within the clinical
tolerance of 0.5 mm. Lee et al [47] also reported promising results from the
compensation circuit. When the distances from the major foramen and CDJ
were measured, the average distance of the measurements was 0.13 mm
from the major foramen with a range of 0.28 to 0.46 mm. The average
distance from the detectable 26 CDJ samples was 0.18 mm with a range of
0.98 to 0.65 mm. The measurement accuracies were 94% (29/31) from the
major foramen and 92% (24/26) from the CDJ with a 0.5 mm tolerance.
There were no dierences between either the smaller (\#25) and larger
apical foramens (#25), or the vital and nonvital pulps, respectively.
Measurements can change as a result of dierent measuring methods
such as what point of the unit the operator uses as a reference and whether
to use the major diameter or the constriction point from the EAL reading.
The operation manual of the Root ZX [48] recommends that the le be
45
inserted until the meter reads 0.5 mm. The le then is advanced with a slow
clockwise turn until the word APEX begins to ash. When the apex is
reached, the le is turned slowly counterclockwise until the meter reads 0.5
mm, and the measurement is then read. The manual also advises that 0.5 to
1 mm be subtracted from the EAL measurements, as indicated by the 0.5
mark on the meter, to place the lling material above the apical seat.
However, several authors have questioned using the 0.5 mark. Some
recommend that the APEX mark be used instead of the 0.5 or 1.0 mark
[25,49].
Ounsi and Naaman [49] performed an in vitro experiment to evaluate the
performance of the Root ZX at two dierent settings: the 0.5 and APEX
marks. The results showed that if the 0.5 mark was selected, the mean value
of the dierence between the EAL and actual length was outside of the
0.5-mm clinical tolerance (50%). However, when the APEX mark was
selected, the mean value was within this tolerance range (84.72%).
Therefore, they discouraged the use of the 0.5 mark as advised by the
manufacturer, and suggested that the canal length be measured when the
APEX mark is reached [49].
Another study [25] evaluated the accuracy of the Root ZX in two
foramen locations: with the foramen at the end of the root tip and with the
foramen deviated from the main axis. The clinical accuracy was 82.75%
with a tolerance level of 0.5 mm when the measurements were read at the
APEX mark. In 28 out of 29 examined teeth, the le tip protruded beyond
the apical foramen with a range between 0.12 mm and 0.85 mm. The authors
of this study [25] recommended the withdrawal of the instrument by
approximately 0.5 to 1 mm to avoid overpreparation.
Similar results were reported for the Endex. Arora and Gulabivala [20]
compared the accuracy of the Endex in the presence of vital and nonvital
pulp tissue and commonly encountered canal electrolytes (pus, NaOCl,
water) with that of a traditional-type EAL, the RCM Mark II. In general,
longer readings occurred with the Endex (80.3%) than with the RCM Mark
II (50.8%). The authors [20] suggested that the manufacturers calibration
of the Endex resulted in an overinstrumentation of the canal length. Mayeda
[31] found that the Endex consistently located a point that was closer to the
major diameter than the apical constriction. Because one third of the
measurements were long, and another one third were right at the apical
foramen, most of the measurements would actually be beyond the apical
constriction. The results indicated that the accuracy of all measurements
were within a narrow range (0.86 mm to 0.50 mm), with 88% at the
0.5-mm clinical tolerance from the major apical foramen. However, if
the readings from the apical constriction instead of the major foramen were
counted, the accuracy would fall to 70% for vital tissue and 69% for
necrotic tissue.
In an in vivo study with a newly designed compensation circuit, Lee et al
[47] reported that most measurements (19/25) were beyond the CDJ. The
46
reason for this was attributed to the fact that the machine reads the largest
gradient of the impedance ratio at the point where the periodontal ligaments
meet. However, the question as to how the measurements could be
reproduced consistently is more important than where to read the
measurements. No matter where the machine points, if the machine
pointing is consistent and the position and the average distance between the
le tip and the true CDJ are known, then an accurate length can be obtained
by subtracting the average distance directly from the machine reading. In
this study [47], the authors used the SDs to evaluate the measurement
consistency. Eighty-one percent of the major foramen and 65% of the CDJ
measurements were within 1 SD, and 97% of the major foramen and 92% of
the CDJ measurements were within 2 SDs. Again, these results showed that
the measurements from the major foramen were more consistent than were
those from the CDJ. The authors [47] suggested that SDs be used to test the
accuracy along with the average discrepancy with the 0.5-mm clinical
tolerance.
Eect of pulpal vitality on the accuracy of EAL
Most studies [24,31,47] have reported that pulpal vitality does not aect
EAL accuracy. Mayeda et al [31] conducted a study to determine whether
the pulp status (ie, vital or necrotic) makes a dierence in the determination.
In this in vivo study, 33 teeth, both vital and necrotic, were measured using
the Endex apex locator and then were radiographed. The results indicated
that all the measurements were within a narrow range (0.86 mm to 0.50
mm). There was no statistical dierence in the measurements between the
vital and necrotic canals (vital group, mean 0.057, SD 0.32 mm,
range 0.71 to 0.5; nonvital group, mean 0.11, SD 0.35 mm,
range 0.86 to 0.43). Similar results were supported by succeeding
investigations with the Root ZX [24] and the newly designed circuit [47].
There have been several disagreements on the eect of pulpal vitality on
the accuracy of EAL. When the inuence of root canal status on the
determination of root canal length using the AFA Apex Finder in vital and
necrotic canals was compared, the results showed a higher accuracy for
determining the apical constriction in vital canals (93.9%) than in necrotic
canals (76.6%), and this dierence was statistically signicant (P 0.05)
[34]. The authors [34] suggested that in necrotic cases with inammatory
root resorption, the apical constriction might be altered or even nonexistent
with no viable periodontal tissue to respond to the EAL, which would cause
a lower accuracy. Arora and Gulabivala [20] reported that the Endex
provided a better reading in vital tissues (88.9%), whereas the readings for
necrotic pulp were substantially lower (45.4%) within a 0.5-mm clinical
tolerance. In a study using the Root ZX, Dunlap et al [50] compared the
canal length in vital and necrotic canals. The mean distance from the
constriction was 0.21 mm in the vital canals and 0.51 mm in the nonvital
47
canals; 52.9% of the vital versus 23.5% of the nonvital readings of the
coronal or right at the apical constriction were measured. However, no
statistical dierence was found. Two necrotic pulps with a periapical
radiolucency measured greater than 1.5-mm error beyond the constriction.
It was conceived that these periapical radiolucencies lacked a periodontal
ligament and the periapical bone may have caused the abnormally long
reading. The authors also speculated that apical resorption by the longstanding periapical radiolucency may have resulted in the destruction of the
apical constriction.
48
that the accuracy of the EAL in apical resorption may depend more on the
operators experience. However, Shabahang et al [23] reported that the Root
ZX could locate the root end consistently, even with the resorption lacunae.
49
steel. The accuracy of the nickel-titanium and stainless steel was 94% and
91%, respectively, and there was no statistically signicant dierence.
Clinical suggestions
Conventional radiograph still is needed
Recent publications regarding frequency-dependent EALs appear to
agree that EALs are more reliable than is conventional radiography.
Whether to trust EALs or radiography depends on how familiar the
operator is with each method. We tend to trust EALs more when there is
a stable electronic sign with reasonably controlled exudates and without any
metallic restorations. However, when the sign is unstableparticularly with
metallic restorations, severely undermined caries, severe exudation, or
a wide-open apexa comparison of the EAL reading with the radiograph is
strongly recommended. Besides, EALs only provide the electronic impedance and not the canal shape. To obtain anatomic information of the roots
and canals, a radiograph still is mandatory in an endodontic procedure.
Working length is changing continuously
The working length changes constantly throughout the root canal
treatment. During the canal preparation procedure, the le inadvertently
may go beyond the apical foramen, breaking the apical constriction and
creating an oval-shaped exit, which leaves a thin wall at the coronal part of
the dentin. As the le tip touches the most coronal margin of the oval exit,
the unit will show an apex sign, thereby measuring a shorter length (Fig. 2B)
than the initial working length (Fig. 2A). This may occur more frequently
because the use of a rotary instrument is increasing in the endodontic
practice. A straightening of the curved canal can be another cause. We
measured the changes in the working lengths between before and after canal
shaping from 5000 root canals using frequency-dependent EAL and showed
that there were some changes in the working lengths (Table 2). EALs were
useful in conrming the working length not only during the endodontic
procedure but also in the nal working immediately before the obturation.
When EALs are used to verify the nal working length, the following things
should be considered. First, the apical area may become too enlarged
leaving an extremely or stripped thin dentin wall. Care needs to be taken so
as not to break the apical seat or the remaining thin dentin wall. A le size
that ts snuggly inside the apical canal is recommended. When the nal
EAL is used in a dried canal situation, the le position may become directly
in contact with the apical soft tissue, where the meter sign of the EAL drops
sharply to the APEX mark. In this case, it is advised to subtract 0.5 to 1 mm,
depending on the size of the apical foramen (usually, a larger subtraction for
a larger-sized foramen).
50
Fig. 2. As the le tip touches the most coronal margin of the oval exit, the unit shows the apex
sign. (A) Initial sign of apex. (B) Sign of apex after canal preparation.
Table 2
Dierence of the working lengths between before and after canal shaping
Root
Upper
Upper
Upper
Upper
Upper
Upper
Upper
Lower
Lower
Lower
Lower
Lower
Dierence (mm)
central incisor
lateral incisor
canine
premolar buccal root
premolar palatal root
molar mesio-buccal root
molar palatal root
central incisor
lateral incisor
canine
rst premolar
rst molar mesio-buccal root
0.3
0.4
0.4
0.3
0.5
0.4
0.4
0.2
0.1
0
0.4
0.4
51
References
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52
53
[29] Wu YN, Shi JN, Huang LZ, Xu YY. Variables aecting electronic root canal
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[30] Lauper R, Lutz F, Barbakow F. In vivo comparison of gradient and absolute impedance
electronic apex locators. J Endod 1996;22(5):2603.
[31] Mayeda D. In vivo measurement accuracy in vital and necrotic canals with the Endex apex
locator. J Endod 1993;19(11):5458.
[32] Frank AL, Torabinejad M. An in vivo evaluation of Endex electronic apex locator. J Endod
1993;19(4):1779.
[33] Pratten DH, McDonald NJ. Comparison of radiographic and electronic working lengths.
J Endod 1996;22(4):1736.
[34] Pommer O, Stamm O, Attin T. Inuence of the canal contents on the electrical assisted
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frequency of overestimated radiographic working length. J Endod 2002;28(2):1169.
[37] Kaufman AY, Keila S, Yoshpe M. Accuracy of a new apex locator: an in vitro study. Int
Endod J 2002;35(2):18692.
[38] Martinez-Lozano MA, Forner-Navarro L, Sanchez-Cortes JL, Llena-Puy C. Methodological considerations in the determination of working length. Int Endod J 2001;34(5):3716.
[39] Goldberg F, De Silvio AC, Manfre S, Nastri N. In vitro measurement accuracy of an
electronic apex locator in teeth with simulated apical root resorption. J Endod 2002;28(6):
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2003;95(1):94100.
[41] Czerw RJ, Fulkerson MS, Donnelly JC, Walmann JO. In vitro evaluation of the accuracy
of several electronic apex locators. J Endod 1995;21(11):5725.
[42] Meares WA, Steiman HR. The inuence of sodium hypochlorite irrigation on the accuracy
of the Root ZX electronic apex locator. J Endod 2002;28(8):5958.
[43] Jenkins JA, Walker WA 3rd, Schindler WG, Flores CM. An in vitro evaluation of the
accuracy of the Root ZX in the presence of various irrigants. J Endod 2001;27(3):20911.
[44] Pilot TF, Pitts DL. Determination of impedance changes at varying frequencies in relation
to root canal le position and irrigant. J Endod 1997;23(12):71924.
[45] Kim DW, Nam KC, Lee SJ. Development of a frequency-dependent-type apex locator with
automatic compensation. Crit Rev Biomed Eng 2000;28(3):4739.
[46] Nam KC, Kim SC, Lee SJ, Kim YJ, Kim NG, Kim DW. Root canal length measurement
in teeth with electrolyte compensation. Med Biol Eng Comput 2002;40(2):2004.
[47] Lee SJ, Nam KC, Kim YJ, Kim DW. Clinical accuracy of a new apex locator with an
automatic compensation circuit. J Endod 2002;28(10):7069.
[48] Operation instructions Root ZX. Tustin (CA): J Morita Manufacturing Corp; 2002. p. 4.
[49] Ounsi HF, Naaman A. In vitro evaluation of the reliability of the Root ZX electronic apex
locator. Int Endod J 1999;32(2):1203.
[50] Dunlap CA, Remeikis NA, BeGole EA, Rauschenberger CR. An in vivo evaluation of an
electronic apex locator that uses the ratio method in vital and necrotic canals. J Endod
1998;24(1):4850.
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54
[54] Beavers RA, Bergenholtz G, Cox CF. Periodontal wound healing following intentional
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[57] Nekoofar MH, Sadeghi K, Akha ES, Namazikhah MS. The accuracy of the Neosono
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J Endod 1998;24(2):1201.
56
Table 1
Composition of nickeltitanium rotary and hand les following an EDAX-analysisa
Composition
File type
Machined
ProFile (Dentsply Maillefer)
Hero 642 (MicroMega)
FlexMaster (VDW-Antaeos)
Hand
NitiFlex K-File (Dentsply Maillefer)
UltraFlex K-File (Texceed)
Onyx-R-File (Union Broach)
Ni
Ti
Al
Fe
Co
54,26
54,37
55,28
45,42
45,32
44,42
0
0
0
0.04
0.05
0.03
0.28
0.26
0.27
54,36
59,14
43,65
45,31
40,40
38,97
0
0
16,74
0.05
0.18
0.33
0.25
0.28
0.24
a
EDAX; Energy Dispersive Analysis of X-rays.
Data from Schafer E. Wurzelkanalinstrumente fur den manuellen Einsatz: Schneidleistung
und Formgebung gekrummter Wurzelkanal abschnitte. Berlin: Quintessenz; 1998.
phase within the speed of sound. A change in shape occurs, together with
volume and density changes. This ability of resisting stress without permanent deformationgoing back to the initial lattice formis called superelasticity. This quality is not unique to NiTi because CuZn, CuAl, AuCd,
and NiNb alloys also show it, but these alloys are less biocompatible [2,4].
The superelasticity is most pronounced at the beginning, when a rst
deformation of as much as 8% strain can be totally overcome. After 100
deformations, the tolerance is about 6% and after 100,000 deformations, it
is about 4% [6,7].
Within this range, the so-called memory eect can be observed: the
NiTi le comes back to its original straight form without showing any sign
Table 2
Properties of nickeltitanium and stainless steel
Property
55 NiTiNOL
60 NiTiNOL
cooled from 950 C
6.45
6.71
Density (g/cm3)
Melting temperature ( C)
1310
1125
Hardness
Vickers
303362
303
Rockwell
(30 above (17 below (30 water(60 furnace
TTR)
TTR)
quenched)
cooled)
Tensile strength (MN/m2) 8271172 103862 945
1062
34138 Near tensile
Yield strength (MN/m2) 621793
strength
Modulus of elasticity
83110
2169
114
114
(103 MN/m2)
Elongation %
115
60
7
Stainless
steel
7.9
15001550
600610
2000
1600
285103 N/mm2
2
57
Fig. 1. The surface of the early NiTi les was rough with grooves and roll overs. Quantec (1997)
is shown in the upper left panel. ProFile (1997) is shown in the upper right panel. An
experimental le (1998) is shown in the lower left panel. Modern surfaces (RaCe) are much
smoother, as shown in the lower right panel.
58
accelerated wear, fatigue, and nally breakage (Fig. 1). Some manufacturers
have overcome this problem (Fig. 2). In addition to inhomogeneities and
surface alterations, corrosion and resistance to repeated sterilization are
issues that must be discussed.
Corrosion and sterilization
The environment of the mouth (body temperature, saliva with its salts
and electrolytes, blood) causes corrosion of NiTi alloys [12,13]. Corrosion
pits in products rich in titanium were described by some authors [1416],
whereas Edie et al [17] saw no dierence in surface characteristics under the
scanning electron microscope or in terms of oxygen contact, meaning
corrosion. United States Navy tests found that NiTi had good corrosion
resistance, good stress corrosion, and performed well in a marine
environment [2].
Dierences in the eects of sterilization on NiTi alloys also have been
fond. Older studies tested orthodontic NiTi wires. One study used dry heat,
formaldehyde vapor, and a steam autoclave. The elastic properties,
resilience, deection rate, and surface were unaltered [18]. Another group
also saw no clinical dierences [19], whereas other researchers observed
a higher stiness, reduced pseudoelasticity, and changes in load and unload
[20].
More recent studies on endodontic instruments indicate that there are
changes but that they are not seen as clinically relevant [12,21,22]. Dry heat
and steam autoclave decreased the exibility of stainless steel and NiTi les,
but the values satised International Standards Organization specications
[12]. These results were conrmed in another study with dierent les in
which sterilization altered the bending moment only slightly [22]. Clinical
use with sodium hypochlorite (NaOCl) and repeated sterilization did not
lead to a decrease in the number of rotations to breakage of the les [21].
Fig. 2. The tips of most les are more or less rounded. LightSpeed is shown in the upper left
panel; GT in the upper right; RaCe in the lower left; and Hero in the lower right., see also Fig. 5.
59
60
Table 3
Chronology and selected data of rotary Nickeltitanium les
Instrument
Year
Cross-section
Taper
Tip
NT Engine
LightSpeed
Mity roto
ProFile
Orice Shaper
PowerR
Quantec
GT rotary
Hero 642
RaCE
FlexMaster
ProTaper
K3
Endostar
NiTi-Tee
K2
MFile
1991
1992
1993
1993
1993
1994
1996
1998
1999
1999
2000
2001
2001
2001
2002
2002
2003
Modied
U le
U le
U le
U le
U le
Modied
U le
Modied
Modied
Modied
Modied
Modied
Modied
Modied
Modied
Modied
02
00
02
0206
0508
0206
0212
04/0612
0206
0210
0206
Multiple/reverse
0210
0210
0212
0208
0206
Pilot
Pilot
Pilot
Pilot
Pilot
Pilot
Various
Pilot
Modied active
Pilot
Modied active
Modied active
Pilot
Pilot
Pilot
Pilot
Pilot
H le
K le
H le
K le
K le
K le
K le
K le
S le
Uni le
K le
of types and brands. The combination of the old idea of 360 rotation with
the new technology met with great success, and progress continues to be
made, even after 15 years.
The sequence of NiTi les opened with NT engine les by McSpadden
and the LightSpeed system by Wildey and Senia [29] and nds its
preliminary end today with the MFile by Brasseler (Table 3). Various NiTi
systems are described throughout this issue and many studies have been
designed to evaluate the advantages and disadvantages of them. A large
number of articles can be found when looking on the Internet for NiTi (424)
or NiTi and dentistry (221). A complete book on root canal treatment with
Ni-Ti instruments has been edited by Quintessence in Germany in 2002 [30]
and many scientists and practitioners around the globe focus on this new
mechanical approach to shape the root canal.
Over the years, three brands have dominated the discussion, the ideas,
and the market: LightSpeed, ProFile, and Quantec, which all share features
that are common and widespread in nearly all systems. During the last
several years, however, there have been some changes in the fundamental
design. A second generation of NiTi instruments, research, and theory has
enabled fast development and improvements that are reviewed here.
International standards organization recommendations
For almost a hundred years, instruments for manual preparation of the
root canal system have been manufactured in a similar way: there are three
main types, namely the reamer, the K le, and the H le. The common
feature of all three is that they have a total cutting length of 16 mm and an
61
62
Fig. 3. The Quantec tip has gone through a special development: from a 60 degree tip (upper
left) and a 90 degree variation (upper right) to a shield tip (lower left) and a torpedo tip (lower
right).
Varying the taper: one of the very new ideas of NiTi le development is
the increase of the standardized taper, which was 2% normally
referring to the International Standards Organization standard (see
Table 3). The rst systems stayed in this tradition (NT Engine, Mity
roto) or created a no-taper variance (LightSpeed), producing parallel
walls for the rst time. Starting with ProFile, the double, triple, and
higher (greater) taper pioneered its way. A double taper or taper
0.04 means that with every millimeter of cutting length, the instrument
gets bigger by 0.04 mm. A triple taper or taper .06 means that with
every millimeter of cutting length, the instrument gets bigger by
0.06mm, and so on. There are not only even taper but some systems
like Quantec, Orice Shapers, and ProTaper also have odd taper.
The ProTaper system (see Fig. 5) dees imagination, having reverse
and multiple taper within one le [32,33].
Fig. 4. Many NiTi le brands show attened cutting edges like LightSpeed (upper left), Quantec
SC with a complex cutting surface (upper right), MFile (notice the change of ute heights;
center), ProFile (lower left), and GT rotary (change of ute heights; lower right).
63
Fig. 5. Recently, a change to sharp cutting edges has been undertaken and some brands show
this variability. FlexMaster is shown in the upper left panel; Hero in the upper right; ProTaper
in the lower left, and RaCe in the lower right. ProTaper shows a variation of taper and a change
from ute height. RaCe exhibits an alternation of twisted and straight areas.
Fig. 6. A shortening of cutting edges is one way to decrease the tendency of NiTi les to screw
into the root dentin. GT rotary les are shown in the upper left panel; MFile in the upper right;
LightSpeed in the lower left, and RaCe in the lower right.
64
(MunchenD) has taper 11% and a tip diameter size 22. The GT rotary les
and System GT also can serve as crown down instruments. The obvious
advantage of all these approaches is that the tip diameters are mostly smaller
than the smallest GG-bur, with size 50 thus needing a comfortable size of the
canal entrance, which cannot be expected anyway. The higher exibility of
NiTi is another point. Another way to overcome this problem has been
developed by FKG, the manufacturer of RaCe les. FKG oers stainless steel
les for crown down (0.08 taper/size 35 and 0.10 taper/size 40).
This discussion reects some of the aspects that have arisen with the
variation of NiTi le designs. A highly interesting monograph dealing with
this subject in extenso is the book Endodontic Instrumentation: Essentials for
Expertise by McSpadden [36], which will be published soon.
This discussion has been closely related to the invention of specic
endodontic motors with torque control. Fatigue, however, is an unsolved
problem and another challenge for NiTi manufacturers. The SET
identitya special box that calculates the cycles and life span of NiTi
lesmay provide an answer (see Fig. 5).
A last aspect under discussion is the enhancement of the surface hardness
of NiTi les. As previously discussed, the NiTi alloy is a strange alloy that
barely can be machined, resulting in a poor surface texture with roll overs
and grooves. Therefore, the possibilities of coating the surface is discussed in
the literature [25,3741].
One approach is ionic implant and thermal nitridation [42]. Lee et al [37]
found that the implantation of 4.8 1017 per ion/cm2 of boron increased
the surface hardness. Another approach is the thermal nitridation for 480
minutes at 500 C or ionic implantation with 150 keV nitrogen ions at doses
of 1.0 1017 per ion/cm2. The wear resistance of ProFiles was enhanced
with both approaches. Regular ProFiles showed a decrease in cutting ability
after 80 seconds, whereas the ionic implantation and thermal nitridation
showed no loss in cutting ability over 240 seconds. Finally, a physical vapor
deposition of TiN also increased the cutting ability [43] and helped the les
to withstand repeated sterilization or exposure to NaOCl [25].
Summary
A large number of studies have dealt with various aspects of NiTi les, such
as the physical and chemical characteristics of NiTi alloys and the original les
available, the biologic acceptance and allergies, the enhancement of cutting
ability and le design using plastic block studies, clinical trials, the question of
torque and fatigue, special motors, scanning electron microscope studies for
testing the cleaning and shaping ability, student studies, and many others (for
review, see reference [30]). There are some leading scientists and companies
that are driving the development of NiTi technology. Side developments of
endodontics such as dierent irrigations and lubricants, new lling methods,
apex locators in combination with high-tech endodontic motors, and others
65
66
[7] NiTi Smart Sheet. West Chester, PA: Johnson Matthey, Inc. Available at: http://
www.sma.-inc.com/html/selected_properties.html. Accessed on January 22, 2004.
[8] Sedgley CM, Messer HH. Are endodontically treated teeth more brittle? J Endod 1992;18:
3325.
[9] Craig RG, Peyton FA. The microhardness of enamle and dentin. J Dent Res 1958;37:6618.
[10] Serene TP, Adams JD, Saxena A. Nickel-titanium instruments. Application in endodontics. St. Louis (MO): Ishiyaku Euro-America; 1995.
[11] Schafer E. Wurzelkanalinstrumente fur den manuellen Einsatz. Schneidleistung und
Formgebung gekrummter Wurzelkanalabschnitte. Berlin: Quintessenz; 1998.
[12] Canaldi-Sahli C, Brau-Aguade E, Sentis-Vilalta J. The eect of sterilization on bending
and torsional properties of K-les manufactured with dierent metallic alloys. Int Endod J
1998;31:4852.
[13] Aten JC. The simulation of clinical corrosion of endodontic les [masters thesis]. Chicago:
Northwestern University of Chicago; 1993.
[14] Sarkar NK, Schwaninger B. The in vivo corrosion of Nitinol wire [abstract]. J Dent Res
1980;59A:528. Abstract 1035.
[15] Clinard K, von Fraunhofer JA, Kuftinec MM. The corrosion susceptibility of modern
orthodontic spring wires [abstract]. J Dent Res 1981;60A:628. Abstract 1277.
[16] Rondelli G, Vicentini B. Localized corrsion behaviour in simulated human body uids of
commercial Ni-Ti-orthodontic wires. Biomaterials 1999;20:78592.
[17] Edie JW, Andreasen GF, Zaytoun MP. Surface corrosion of Nitinol and stainless steel
under clinical conditions. Angle Orthod 1981;51:31924.
[18] Mayhew MJ, Kusy RP. Eects of sterilization on the mechanical propeties and the surface
topography of nickel-titanium arch wires. Am J Orthod Dentofac Orthop 1988;93:2326.
[19] Smith GA, von Fraunhofer JA, Casey GR. The eect of clinical use and sterilization on
selected orthodontic arch wires. Am J Orthod Dentofac Orthop 1992;102:1539.
[20] Kapila S, Haugen JW, Watanabe LG. Load-deection characteristics of nickel-titanium
alloy wires after clinical recycling and dry heat sterilization. Am J Orthod Dentofac Orthop
1992;102:1206.
[21] Yared GM, Bou dagher FE, Machtou P. Cyclic fatigue of ProFile rotary instruments after
clinical use. Int Endod J 2000;33:2047.
[22] Briseno Marroquin B, Willershausen B. Inuence of dierent sterilisation procedures on
the bending moment of stainless steel and nickel titanium root canal instruments [abstract].
J Endod 1999;25:288. Abstract OR23.
[23] Rapisarda E, Bonaccorso A, Tripi TR, Condorelli GG. Eect of the sterilization on the
cutting eciency of rotary-nickel-titanium endodontic les. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1999;88:3437.
[24] Busslinger A, Sener B, Barbakow F. Eects of sodium-hypochlorite on nickel-titanium
LightSpeed instruments. Int Endod J 1998;31:2904.
[25] Schafer E. Eect of sterilization on the cutting eciency of PVD-coated nickel-titanium
endodontic instruments. Int Endod J 2002;35:86772.
[26] Basketter DA, Briatico-Vangosa G, Kaestner W, Lally C, Bontinck WJ. Nickel, cobalt and
chromium in consumer products: a role in allergic contact dermatitis? Contact Dermatitis
1993;28:1525.
[27] Putters JL, Kaulesar SuKul GM, de Zeeuw GR, Bijma A, Besselink PA. Comparative cell
culture eects of shape memory metal (nitinol), nickel and titanium: a biocompatibility
estimation. Eur Surg Res 1992;24:37882.
[28] Ryhanen J. Biocompatibility evaluation of nickel-titanium shape memory alloy
[dissertation]. Oulu, Finland: University of Oulu; 1999.
[29] Wildey WL, Senia S. A new root canal instrument and instrumentation technique:
a preliminary report. Oral Surg Oral Med Oral Pathol 1989;67:198.
[30] Hulsmann M. Wurzelkanalaufbereitung mit Nickel-Titan-Instrumenten. Ein Handbuch.
Berlin: Quintessenz; 2002.
67
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.11.006
70
engaging the wall [3]. After the merge of the Tulsa Dental and Dentsply
companies in 1998, GT rotary instruments and ProFile 0.04 taper and 0.06
taper with International Standards Organization (ISO)-sized tips were
marketed. The ProFile ISO-sized tip system was more popular in Asia and
Europe. Today, the ProFile system is one of the best-selling rotary instrument
systems in the world. The following section thoroughly reviews this system.
Unique le design
Cross-sectional geometry
The ProFile instrument family, including Prole 0.04 and 0.06 taper,
Orice Shapers, and GT les, all have the same cross-sectional geometry.
The shape is made by machining three equally spaced U-shaped grooves
around the shaft of a taper NiTi wire. There is a central parallel core inside
that may account for the enhanced exibility compared with Quantec
(Tycom, Irvine, California) [4] and ProTaper (Dentsply International, York,
Pennsylvania) [5], which possess a tapered central core. It has a 20 negative
rake angle at the cutting edge and at radial lands to cut dentin in a planing
motion. These congurations prevent the instrument from screwing into
the canal while rotating. The radial lands also add peripheral mass that
contributes signicantly to the strength of the instrument. The U-shaped
grooves provide the space to accommodate dentin shavings while planing of
the canal wall. The 20 helical angle was designed to remove the shaving
debris coronally while the instrument rotates clockwise.
Every ProFile le has a bullet-nosed tip with a rounded transition angle.
This noncutting tip will follow a pilot hole and guide the instrument into the
canal. The noncutting tip and symmetric radial lands design allow the le to
remain self-centered as it rotates through 360 , theoretically decreasing the
potential for canal transportation and procedural errors to occur [6,7].
Series 29
The rate of increase between le sizes in this series is at a constant of
29%. It is claimed that fewer instruments are required to enlarge to master
apical le size. Table 1 shows the size equivalents of Series 29 instruments
compared with ISO sizing. In contrast to a 50% size increase between ISO
size 10 and size 15 and a 33% increase between size 15 and size 20, the 29%
increment has the advantage of smooth transition among the smaller sizes.
There is a much greater leap of size increment in larger les, however, which
may create diculties and complications while shaping curved canals [3].
The ProFile system with increased tapers has been developed in the hope
that the greater are along the instrument shaft would automatically create
the divergence required for obturation. The taper of the instrument aects
the increase in diameter along its length. In a standard 0.02 taper le, the
diameter increases by 0.02 mm per millimeter from the tip (D0). Thus, D16,
which is the le diameter 16 mm away from D0, is 0.32 mm wider than D0.
71
Table 1
Size equivalents of ProFile Series 29 and standard ISO sizing
ProFile Series 29 size
2
3
4
5
6
7
8
9
10
0.129
0.167
0.216
0.279
0.360
0.465
0.600
0.775
1.000
For a 0.04 taper instrument, D16 is 0.64 mm wider than D0, and for a 0.06
taper instrument, D16 is 0.96 mm wider than D0 [3,8].
The GT le has a xed D0 diameter of 0.20 mm and a xed maximal ute
diameter of 1.0 mm. As such, dierent degrees of taper account for dierent
lengths of blade.
Clinical performance
The clinical performance of the ProFile system in general is rated good
and is comparable to other NiTi rotary systems [4,7,9]. For a more detailed
discussion, the clinical performance of the ProFile system is divided into the
following sections: cutting/machining eciency, shaping ability, cleaning
ecacy, and eect of NaOCl and sterilization.
Cutting/machining eciency
Machining eciency has been dened as the procedure of removal of
simulated canal/tooth substance with the uted material. Machining
eciency has been shown to relate to the alloy used and to cross-sectional
geometry [10]. Hakel and colleagues [11] dened cutting eciency as the
mass of Plexiglass cut per unit of energy used by the test le. Hakel and
other investigators [11,12] found that the NiTi les cut less eciently than
stainless steel les. This reduction in eciency may be explained by the fact
that NiTi has a very low modulus of elasticity and, thus, deformation on
contact with simulated canal/tooth substance is induced. Kazemi et al [13]
demonstrated that NiTi les are comparable with or better than stainless
steel les in terms of machining dentin. The divergent results may be due to
the dierent behavior of les when cutting Plexiglass and dentin substrate.
Dr. Johnson [14] classied all rotary instruments as having active,
semiactive, or passive cutting blades. The ProFile system ts into the category
of passive instruments. The slight negative rake angle and radial lands make
the les cut less aggressively than those having active cutting blades (eg,
ProTaper [15], HERO 642 [Micro-Mega, Besancan, France], RaCe File [FKG
72
73
Safety concerns
Although NiTi rotary instruments have the advantages of superelasticity,
shape memory, and good eciency with less fatigue, their use does have
74
75
76
le to enter the canal. When the instrument is rotating, it should be used with
gentle in-and-out movements (pecking motion) to prevent the stress from
building up. Each le is used only for a short time and should never be left
rotating in a stationary position. Most important, instruments should be
discarded after a certain number of uses [14]. Peters and Barbakow [46]
measured the number of rotations to failure in a cyclic fatigue test and then
divided this number by the average of rotations for preparing an individual
canal. Their result indicated that up to 5 to 10 curved canals could be safely
prepared with the ProFile 0.04 taper instrument [46]. Taking the complex
anatomy of root canals and the torque generated for torsional fracture into
account, the manufacturer of ProFile recommends that the les be discarded
after 6 to 8 clinical uses. Because fracture of NiTi instruments can occur
without evidence of unwinding and deformation, it is advised to discard
instruments after abuse in an extremely curved or narrow canal.
Gambarini [47] suggested the use of low-torque endodontic motors to
reduce the mechanical stress on NiTi rotary instruments. The torque value
for an individual instrument is set at slightly lower than the limit of
elasticity, and these data are preprogrammed in the machine. If the motor is
loaded up to the torque limit, the motor stops momentarily or rotates
backward to avoid permanent deformation and intracanal breakage [47].
Using a torque-control unit, however, may lead the instrument to repeatedly
move in a forward and reverse motion, resulting in increased cyclic fatigue
[14]. Yared and Sleiman [48] demonstrated that for an experienced operator,
there was no dierence in the failure incidence of ProFile instruments used
with air, high torque-control motors, or low torque-control motors. In
contrast, for an inexperienced operator, use of the low torque-control unit
can signicantly reduce the incidence of intracanal breakage [48].
ProFile and other NiTi rotary instruments should be operated with
constant speed. The recommended speed for the ProFile system ranges from
250 to 350 rpm. For an experienced operator, rotational speed within that
specic range may not be as critical as for an inexperienced operator. Yared
et al [48,49] demonstrated that use of ProFile in a crown-down manner at
350 rpm is safe for an experienced operator. Daugherty et als [50] study
suggested that the ProFile 0.04 taper Series 29 rotary instruments should be
used at 350 rpm to double the eciency and halve the deformation rate
compared with the 150 rpm group. For an inexperienced operator, however,
using the slower speed of 150 to 170 rpm would be more likely to prevent
instruments from deformation and fracture [49].
Clinical applications
Cleaning and shaping of the root canal system
The fundamental concepts for cleaning and shaping of a root canal system
remain the same regardless of the techniques and instruments used. Obtaining
77
a straight line access into the orice and canal is the rst critical step for
successful outcome. Any overhanging dentins from the chamber roof and
cervical ledges near the orices have to be removed. The preparation should be
extended to eliminate any coronal interference during subsequent instrumentation [3]. After the coronal access is completed and canal orices are identied, the chamber is debrided by copious irrigation with NaOCl. Ultrasonics
and chelating agents such as EDTA also can be used before canal preparation.
Pre-enlargement of the coronal two thirds of the canal has mechanical
and biologic benets. Mechanically, pre-enlargement allows early removal
of coronal interferences, thus aiding in better tactile sensation of the le
moving apically. It also minimizes canal deviation and instrument separation by reducing contact with the canal. Biologically, pre-enlargement
facilitates rapid removal of contaminated tissue from the canal system and
improves the penetration of irrigation solution. It minimizes extrusion of
debris apically and subsequent post-treatment are-ups [38]. Prearing also
provides more accurate and consistent working length determination [39]
and, therefore, more precise canal cleaning and shaping. Also, obturation
can be accomplished without violating surrounding periradicular tissue.
Pre-enlargement of the coronal two thirds can be accomplished with
a variety of instruments such as Gates-Glidden (GG) burs, Orice Shapers,
GT les, and any NiTi rotary system with greater tapers in either crown
down or step back manner. Dr. Ruddle [3] suggested using NiTi rotary les
in a crown-down technique or GG burs in a stepback technique to complete
coronal preparation. The author prefers using GG burs in a crown down
direction, with GG bur 4 submerging the cutting head below the orice and
each smaller GG stepping into canal for about 2 to 3 mm until reaching the
predetermined depth. No matter what instrument or what sequence is
selected, it is important to insert a stainless steel hand le (0.02 taper, size 10,
size 15) to the level at least 2 mm deeper than the desired depth for the
rotary instruments. The advantages for such a procedure are twofold. First,
it gives information about canal anatomy regarding to the curvature and
width. Second, it creates a patent pathway for the rotary instruments. The
reason for hand les to reach the level 2 mm beyond the rotary instrument is
to preserve the most apical canal anatomy for future hand le advancement.
The goals for pre-enlargement are to relocate the canal away from the
anatomic danger zone and to achieve uninhibited access to the apical third
of the canal, yet still preserve enough root structure for prosthetic restoration. The entire pre-enlargement procedure should be done with copious
irrigation and frequent recapitulation to ensure canal patency [3,38].
After pre-enlargement of the coronal two thirds, the clinician is ready to
advance the stainless steel hand le to the apical terminus. The clinician
should mentally picture the canal anatomy before use of rotary instruments.
In cases where canals merge (Weines classication type II), canals divide
(Weines classication type IV), and in bayonet-shaped canals, NiTi rotary
instruments will bind to the dentinal wall and fracture. Therefore, these
78
79
80
Fig. 1. (A,B) Prepared with 0.06 taper ProFile in a gently curved maxillary second molar.
friction generated by ProFile instruments can soften the gutta percha and
move it coronally [52]. Baratto and colleagues [53] evaluated the eectiveness
of the ProFile 0.04 taper to remove gutta-percha. They found that ProFile
could reach ideal working length rapidly regardless of the obturation
techniques but was inadequate in complete removal of gutta-percha. To
ensure the complete removal of gutta percha, the clinician might use ProFile
to remove the bulk of gutta-percha, thus providing space for chemical
solvent. With the aid of a microscope, the clinician can try to wipe or wick
out the residual gutta percha from the canal aberrations with paper points.
Summary
NiTi rotary instruments have advanced endodontics into another era.
The ProFile rotary instrument system has good clinical performance in
managing curved canals and has proved to be more ecient than hand
instrumentation. Our professional responsibilities include making the best
use of this system and providing the best quality of care to our patients.
81
Fig. 2. (AC) Prepared with 0.04 taper ProFile in a moderately curved mandibular second
molar. Noted that a separated #10 K hand le in the apical third of distal canal, which was
bypassed and lled to the apex.
82
There is a learning curve before prociency and ProFile use must follow the
principles listed below [3]:
1. Coronal and radicular straight line access are essential to proper
cleaning and shaping and to reduce risk of instrument separation.
2. Always use hand instrument to explore canal anatomy and obtain
a pathway before introducing rotary instruments.
3. Adhere to the recommended rotational speed. For an inexperienced
operator, following the sequences provided by the manufacturer may
result in less frustration. Practice on the extracted teeth before use in
vivo.
4. Make sure to always have enough lubrication in the canal and work
passively on rotary les. Never force the instrument to advance
apically.
5. Understand the limitation of NiTi rotary instruments. Dicult canal
anatomy such as canal merge, abrupt curvature, and bayonet-shaped
canals may not be appropriate for their use.
83
References
[1] Walia H, Brentley W, Gerstein H. An initial investigation of the bending and torsional
properties of Nitinol root canal les. J Endod 1988;14:34650.
[2] Thompson SA. An overview of nickel-titanium alloys used in dentistry. Int Endod J 2000;
33:297310.
[3] Ruddle CJ. Cleaning and shaping the root canal system. In: Cohen S, Burns RC, editors.
Pathways of the pulp. 8th edition. St. Louis (MO): Mosby; 2002. p. 23191.
[4] Peters OA, Schonenberger K, Laib A. Eects of four Ni-Ti preparation techniques on
root canal geometry assessed by micro computed tomography. Int Endod J 2001;34:
22130.
[5] Berutti E, Chiandussi G, Gaviglio I, et al. Comparative analysis of torsional and bending
stresses in two mathematical models of nickel-titanium rotary instruments: ProTaper
versus ProFile. J Endod 2003;29:159.
[6] Bryant ST, Thompson SA, Al-Omari MAO, et al. Shaping ability of Prole rotary nickeltitanium instruments with ISO sized tips in simulated root canal: Part 1. Int Endod J 1998;
31:27581.
[7] Thompson SA, Dummer PMH. Shaping ability of Prole .04 taper Series 29 rotary nickeltitanium instruments in simulated root canals. Part 1. Int Endod J 1997;30:17.
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.06 taper instruments. Endod Dent Traumatol 1998;14:1620.
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using Prole .04 and Lightspeed rotary Ni-Ti instruments. Int Endod J 2002;35:3746.
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[21] Short JA, Morgan LA, Baumgartner JC. A comparison of canal centering ability of four
instrumentation techniques. J Endod 1997;23:5037.
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[23] Rodig T, Hulsmann M, Muhge M, et al. Quality of preparation of oval distal root
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[24] Bystrom A, Sundqvist G. Bacteriologic evaluation of the ecacy of mechanical root canal
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[25] Bystrom A, Sundqvist G. Bacteriologic evaluation of the eect of 0.5 percent sodium
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[26] Bystrom A, Sundqvist G. The antibacterial eect of camphorated paramonochlorophenol,
camphorated phenol and calcium hydroxide in the treatment of infected root canals.
Endod Dent Traumatol 1985;1:1705.
[27] Dalton BC, rstavik D, Phillips C, et al. Bacterial reduction with nickel-titanium rotary
instrumentation. J Endod 1998;24:7637.
[28] rstavik D, Kerekes K, Molven O. Eects of extensive apical reaming and calcium
hydroxide dressing on bacterial infection during treatment of apical periodontitis: a pilot
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[29] Card SJ, Sigurdsson A, rstavik D, et al. The eectiveness of increased apical enlargement
in reducing intracanal bacteria. J Endod 2002;28:77983.
[30] Shuping GB, rstavik D, Sigurdsson A, et al. Reduction of intracanal bacteria using
nickel-titanium rotary instrumentation and various medications. J Endod 2000;26:7515.
[31] Peters OA, Barbakow F. Eects of irrigation on debris and smear layer on canal walls
prepared by two rotary techniques: a scanning electron microscopic study. J Endod 2000;
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[32] Ha kel Y, Serfaty R, Speisser JM, et al. Mechanical properties of nickel-titanium
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[35] Serene TP, Adams JD, Saxena A. Introduction to nickel-titanium. In: Serene TP, Adams
JD, Saxena A, editors. Nickel-titanium instruments application in endodontics. St. Louis
(MO): Ishiyaku EuroAmerica; 1995. p. 15.
[36] Silvaggio J, Hicks ML. Eect of heat sterilization on the torsional properties of rotary
nickel-titanium endodontic les. J Endod 1997;23:7314.
[37] Mayhew JT, Eleazer PD, Hnat WP. Stress analysis of human tooth root using various root
canal instruments. J Endod 2000;26:5234.
[38] Gutmann JL. The crown-down technique: the standard of excellence for root canal
cleaning and shaping in contemporary endodontics. In: Wei S, editor. Contemporary
endodontics. Hong Kong: Dentsply Asia; 2002. p. 710.
[39] Ibarrola JL, Chapman BL, Howard JH, et al. Eects of prearing on RootZX apex
locators. J Endod 1999;25:6256.
[40] Hinrichs RE, Walker WA III, Schindler WG. A comparison amounts of apically
extruded debris using handpiece-driven nickel-titanium instrument systems. J Endod
1998;24:1026.
[41] Reddy SA, Hicks ML. Apical extrusion of debris using two hand and two rotary
instrument techniques. J Endod 1998;24:1803.
[42] Pruett JP, Clement DJ, Carnes DL. Cyclic fatigue testing of nickel-titanium endodontic
instruments. J Endod 1997;23:7785.
[43] Sattapan B, Palamara JEA, Messer HH. Torque during canal instrumentation using rotary
nickel-titanium les. J Endod 2000;26:15660.
[44] Sattapan B, Nervo GJ, Palamara JEA, et al. Defects in rotary nickel-titanium les after
clinical use. J Endod 2000;26:15660.
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[45] Ha kel Y, Serfaty R, Bateman G, et al. Dynamic and cyclic fatigue of engine-driven rotary
nickel-titanium endodontic instrument. J Endod 1999;25:43440.
[46] Peters OA, Barbakow F. Dynamic torque and apical forces of ProFile .04 rotary
instruments during preparation of curved canals. Int Endod J 2002;35:37989.
[47] Gambarini G. Rationale for the use of low-torque endodontic motors in root canal
instrumentation. Endod Dent Traumatol 2000;16:95100.
[48] Yared GM, Sleiman P. Failure of Prole instruments used with air, high torque control,
and low torque control motors. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;
93:926.
[49] Yared GM, Bou Dagher FE, Machtou P. Inuence of rotational speed, torque and
operators prociency on Prole failures. Int Endod J 2001;34:4753.
[50] Daugherty DW, Gound TG, Comer TL. Comparison of fracture rate, deformation rate,
and eciency between rotary endodontic instruments driven at 150 rpm and 350 rpm.
J Endod 2001;27:935.
[51] Hembrough MW, Steiman HR, Belanger KK. Lateral condensation in canals prepared
with nickel titanium rotary instruments: an evaluation of the use of three dierent master
cones. J Endod 2002;28:5169.
[52] Ruddle CJ. Nonsurgical endodontic retreatment. In: Cohen S, Burns RC, editors.
Pathways of the pulp. 8th edition. St. Louis (MO): Mosby; 2002. p. 875929.
[53] Baratto Filho F, Ferreira EL, Fariniuk LF. Eciency of the 0.04 taper ProFile during the
re-treatment of gutta-percha-lled root canals. Int Endod J 2002;35:6514.
ProTaper NT system
Thomas Clauder, DDSa,b,*, Michael A. Baumann,
DDS, PhD, Univ.-Prof. Dr. med. dent.c
a
88
Fig. 1. Radiograph showing a severely curved upper premolar with two joining canals.
(Courtesy of Thomas Clauder, DDS.)
89
Fig. 2. This tooth was cleaned and shaped with ProTaper les. (Courtesy of Thomas Clauder,
DDS.)
90
Fig. 3. The set of six ProTaper les includes three shaping les and three nishing les.
Fig. 4. Scanning electron microscope (SEM) picture demonstrating the modied guiding tip
of a ProTaper le. (From Baumann MA. ProTapera new generation of NiTi-les in
endodontics. Endodontie 2001;10:353; with permission.)
91
Fig. 5. SEM picture demonstrating the cutting blades of a ProTaper le. (From Baumann MA.
ProTapera new generation of NiTi-les in endodontics. Endodontie 2001;10:353; with
permission.)
cutting eciency that was not possible previously. In the same process, it is
possible to reduce the torsional strain and ease the pressure to achieve
widening of the root canal. In comparison with other le geometries with
radial lands that produce a passive cutting and scraping action, the
ProTaper system works with an active cutting motion, which substantially
increases the eectiveness of the system and reduces torsional strain [4].
Regarding instrument geometries, only F3 has a reduced cross-section with
a U-shape to facilitate a higher degree of exibility (Figs. 7 and 8).
Fig. 6. SEM picture demonstrating the convex, triangular cross-section of the ProTaper les.
(From Baumann MA. ProTapera new generation of NiTi-les in endodontics. Endodontie
2001;10:353; with permission.)
92
Fig. 7. SEM picture demonstrating the cutting blades of F3 with a reduced core. (From
Baumann MA. ProTapera new generation of NiTi-les in endodontics. Endodontie
2001;10:353; with permission.)
Furthermore, new design features are the variable helical angel and
balanced pitches in the instrument, which improve cutting action, allow for
better removal of debris out of the root canal, and prevent the instrument
from screwing into the canal. The length of the le handle of the instruments
was reduced from 15 mm to 12.54 mm to allow for better access in dicult
Fig. 8. SEM picture demonstrating the cross-section of F3 with a reduced core. (From
Baumann MA. ProTapera new generation of NiTi-les in endodontics. Endodontie
2001;10:353; with permission.)
93
Fig. 9. This graphic model, overlapping the taper of ProTaper instruments, shows the complex
design of the instruments.
posterior areas, which could compromise the treatment result. The les are
available in 21- and 25-mm lengths.
Instrument design
Shaping les
The ProTaper system features six NiTi les, the rst of which is the
auxiliary shaping le, called Shaper X or SX. SX is recognized by its lack of an
identication ring on its handle and its extraordinary shape, reminding Prof.
Pierre Machtouone of the three specialists involved in the development of
Fig. 10. Straight-line access is of major importance, especially in complex canal systems such as
the obturated c-shaped lower molar. (Courtesy of Thomas Clauder, DDS.)
94
Fig. 11. The le in the unshaped canal gives information about the angulation of the coronal
part of the canal. (Courtesy of Cliord J. Ruddle, DDS.)
the systemof the Eiel Tower in Paris (see Fig. 3). SX is available with
cutting blades of 14 mm and a tip diameter of 0.19 mm. All of the ProTaper
shaping les have a progressively increasing taper; SX has the highest
increase. At D6, D7, D8, and D9, the cross-sectional diameter increases from
0.50 mm, 0.70 mm, 0.90 mm, and 1.10 mm, according to a taper of 11%,
14.5%, 17%, and 19%, respectively. The total increase of taper in SX from D0
to D9 is dened with nine dierent tapers from 3.5% to 19%.
Fig. 12. With brushing motions, the canal orice has to be relocated to achieve straight-line
access to the apical region of the canal. (Courtesy of Cliord J. Ruddle, DDS.)
95
Fig. 13. Shaping with SX leads to removal of the overlapping dentin walls and allows for
straight-line access. (Courtesy of Cliord J. Ruddle, DDS.)
The complex le design allows for ideal and ecient shaping of the
coronal aspects of the root canal and the relocation of canal orices,
resulting in a straight-line access. The relocation of the canal orices should
be in the direction of overhanging dentin areas and away from danger
zones in furcation areas and thinner dentin walls, where strip perforations
can compromise treatment objectives. The instrument is used in a brushing
motion and is designed to replace Gates-Glidden drills (Dentsply Maillefer,
Fig. 14. Precise determination of working length and establishing patency with hand les are
key factors for further cleaning and shaping procedures. (Courtesy of Cliord J. Ruddle, DDS.)
96
Fig. 15. S1 and S2 are carried to working length, shaping primarily the coronal two thirds of
the canal, but also pre-enlarging the apical area. (Courtesy of Cliord J. Ruddle, DDS.)
Ballaigues, Switzerland). The diameter at D10 is 1.11 mm, which corresponds to a Gates-Glidden drill size of four.
Shaping le 1 (S1) has a purple identication ring and shaping le 2 (S2)
has a white identication ring on their handles (see Fig. 3). The diameter at
the tip of S1 is 0.19 mm and of S2 is 0.20 mm. Both instruments have an
increasing taper over the whole working range, although the increase is not
as aggressive as that of SX. S1 has an increasing taper from 2% on D1 to
Fig. 16. Gauging the apical canal diameter provides further information that inuences the
nishing criteria. (Courtesy of Cliord J. Ruddle, DDS.)
97
Fig. 17. ProTaper les, used in the described sequence, engage special sections of the root canal
shown in the graphic.
Fig. 18. Radiograph showing a curved lower molar instrumented with ProTaper rotary les.
(Courtesy of Thomas Clauder, DDS.)
98
99
Fig. 19. ProTaper les were used for hand instrumentation to instrument the extreme curvature
of the lower molar. (Courtesy of Thomas Clauder, DDS.)
a le; only a light brushing motion should be used to achieve the desired
results.
Straight-line access
An ideal access cavity preparation is very important to successful
treatment, independent from the le system and the technique used (Fig. 10).
To avoid staining the les unnecessarily and instrumenting unnecessary
curvatures, it is necessary to achieve a straight-line access and to reduce all
overlapping dentin areas. The ProTaper SX le may be used to remove the
triangle of dentin rapidly, eectively, and safely [1,10]. Furthermore, it has
to be ensured that all orices can be viewed on the mirror without any
movement of it. In addition, access cavities should be reshaped so that
a straight-line access to apical regions can be achieved. The angle of the
inserted instrument is a good indicator: if straight-line access has been
achieved, the instrument should stand upright (Fig. 11) [1]. The angulations
after the initial crown down should be parallel to the axis of the tooth to
ensure the most eective cutting eciency in the regions of application. A
recent study showed that the ProTaper Systemlike most other rotational
100
Fig. 20. Previous endodontic treatment resulted in persisting apical periodontitis and is a source
of acute symptoms. (Courtesy of Thomas Clauder, DDS.)
101
Fig. 21. The ProTaper les also can be used for retreatment cases. This postoperative
radiograph shows the tooth after instrumentation and obturation of all four canals. (Courtesy
of Thomas Clauder, DDS.)
102
Fig. 22. This interesting canal anatomy was cleaned and shaped with ProTaper les. (Courtesy
of Thomas Clauder, DDS.)
shaping with SX then can be started. SX is inserted while rotating into the
root canal. If a light resistance is felt on the instrument, the le is withdrawn
and worked in a brushing motion against the dentin wall of choice (Fig. 12)
[1,6]. Repeating this procedure allows for deeper insertion of the instrument,
enabling the removal of all overlapping dentinal walls and a perfect coronal
shape of the root canal. It is important to inspect the instrument after each
use to prevent fractures of the instrument. Deformed instruments must be
discarded immediately. Shaping with SX should result in generous dentin
removal; inadequate widening of the coronal aspects of the root canal can
complicate and slow down further instrumentation, because following
instruments can get stuck in thin coronal parts of the canal. After the initial
crown down is nished, the les inserted into the root canal should be
parallel to the axis of the root (Fig. 13).
After the initial crown down, the working length is conrmed and
patency is established (Fig. 14). A #10 K-le is inserted passively into the
canal. Working length should be checked with an electronic apex locator
and conrmed with a well-angulated radiograph. Patency is of great
importance and must be maintained during the complete shaping procedure
103
Fig. 23. Straight forward cases can be shaped without procedural errors. (Courtesy of
Thomas Clauder, DDS.)
104
Fig. 24. The lower molar was shaped for three-dimensional obturation of the root canals.
(Courtesy of Thomas Clauder, DDS.)
105
Fig. 25. Anatomic variations, like this premolar with three roots, can be introduced with the
system. (Courtesy of Thomas Clauder, DDS.)
preparation is done with the nishing les. For apical gauging and shaping
the technique preferred by Dr. Cliord Ruddle is as follows [12].
The last instrument reaching working length is S2, which has a diameter
of 0.20 mm at the instrument tip and a taper of 4%. F1, which has the same
diameter at the instrument tip, can be worked to working length. Due to the
design of the le, a uniform taper of 7% is produced in the apical portion of
the root canal. The apical diameter of the root canal is gauged with a #20
K-le. The instrument is inserted passively into the canal to working length,
tapping on the head of the instrument to prevent cutting action. If the le
binds in the apical region, the preparation is nished. If the le is loose in the
canal, F2 is inserted to working length. Apical gauging should be repeated
now with a #25 K-le. During this procedure, attention is given to maintain
working length. Does the #25 K-le bind at working length preparation of
the root canal is nished, if the le is loose in the canal, F3 should be used to
working length. Apical gauging should be repeated now with a #30 K-le
(Fig. 16). Does the #30 K-le bind at working length preparation of the root
canal is nished, if the le is loose in the canal a dierent technique should
be chosen to nish apical preparation. With the second use of S1, all
106
Fig. 26. The micro-CT evaluation demonstrates the canal anatomy of an upper molar before
instrumentation. (From Peters OA, Peters CI, Schoneberger K, Barbakov F. ProTaper rotary
root canal preparation: eects of canal anatomy on nal shape analyzed by microCT. Int
Endod J 2003;36:87; with permission.)
107
Fig. 27. The micro-CT evaluation demonstrates the canal anatomy of an upper molar after
cleaning and shaping procedures with ProTaper les. (From Peters OA, Peters CI, Schoneberger
K, Barbakov F. ProTaper rotary root canal preparation: eects of canal anatomy on nal shape
analyzed by microCT. Int Endod J 2003;36:87; with permission.)
Summary
Root canal instrumentation should provide a tapered, adequate canal
shape to allow for eective irrigation and obturation [18]. This can be
accomplished thoroughly with the ProTaper NiTi system (Figs. 22 and 23).
The well-planned le design allows for an ideally prepared root canal of easy
or dicult shape (Figs. 24 and 25). The nish of the root canal instrumentation allows for a predictable obturation of the root canal system,
independent of technique chosen. ProTaper instruments adequately open
canals 5 mm from their apices, with sizes varying from 0.65 mm to 0.79 mm.
Spreaders and pluggers with 0.50-mm tips can be used readily during obturation of root canals with such apical preparations [11]. They also can be
used for antibacterial therapy, allowing for a thorough irrigation technique.
108
Fig. 28. Superimposing pre- and postoperative data demonstrates the shape created with
ProTaper les following canal anatomy. (From Peters OA, Peters CI, Schoneberger K,
Barbakov F. ProTaper rotary root canal preparation: eects of canal anatomy on nal shape
analyzed by microCT. Int Endod J 2003;36:89; with permission.)
After the ProTaper system was introduced, the possibility of more or less
severe canal transportation produced by active cutting action was discussed.
The latest evidence shows that canals can be prepared with the ProTaper
system without major procedural errors (Figs. 2628) [11,19]. Micro-CT
evaluation of shaped canal studies showed that the ProTaper System tends
to transport canals slightly larger than do le systems with a passive cutting
action [11]. Therefore, it is important to immediately remove the instrument
out of the root canal once working length is achieved. A prolonged rotation
of the instrument with an active cutting blade can lead to unnecessary
misshapes in canal anatomy. This tendency can be minimized by achieving
proper coronal shaping and straight-line access (Fig. 29). Straight-line
access helps to minimize transportation during the shaping procedure [11].
Another study [19] has shown no transportation in the middle section of the
tooth and in apical areas, and little transportation in coronal areas toward
furcation areas. A center displacement toward the furcation area also has
been demonstrated with several NiTi systems on the market [19], but
obviously is not as severe as with a standardized instrumentation technique
using stainless steal instruments [3].
109
Fig. 29. Sections of treated extracted teeth with ProTaper instruments show a centered
preparation allowing for complete obturation.
110
seems to minimize fracture risk of the instrument [13]. Apical instrumentation with K-les is extremely important in these cases. In addition,
discarding instrumentsafter or during usethat have been used in
calcied canals helps to minimize the fracture risk of the instrument.
Mathematic models have conrmed that in case of similar apical loads,
ProTaper instruments work longer in a super elastic phase than do
instruments with a U-le design, allowing for high performance and less risk
[20]. The system enables a safe of time compared with hand instrumentation
techniques, especially in simple and predictable cases. In more dicult cases,
the advantage lies in the perfect preparation of the root canal.
The operator should decide on the size of the apical instrumentation
according to the preferred treatment concept, the scientic background, and
the special case selected. If the apical regions are to be enlarged wider than
ISO 30 in large canals, it might be best to use a dierent technique to achieve
the treatment goal rather than using the ProTaper system. Recent studies
have shown that the ProTaper system perfectly shapes curved and constricted
canals [11,13,15]. Wide canals were less eciently instrumented, which is
apparent as the design features and sizes available suite less [11]. Combining
ProTaper system with other NiTi systems emphasize the advantages of the
ProTaper system can provide larger apical sizes. This is discussed in the
article on hybridization of le systems elsewhere in this issue.
References
[1] Ruddle CJ. The ProTaper technique. Endod Prac 2002;5:2230.
[2] Peters OA, Schoneberger K, Laib A. Eects of four NiTi preparation techniques on root
canal geometry assessed by micro computed tomography. Int Endod J 2001;34:22130.
[3] Gluskin AH, Brown DC, Buchanan LS. A reconstructed computerized tomographic
comparison of Ni-Ti rotary GT les versus traditional instruments in canals shaped by
novice operators. Int Endod J 2001;34:47684.
[4] Turpin YL, Chagneau F, Bartier O, Cathelineau G, Vulcain JM. Impact of torsional and
bending inertia on root canal instruments. J Endod 2001;27:3336.
[5] Baumann MA. ProTaperEine neue Generation von Ni-Ti-Feilen [ProTapera new
generation of NiTi-les in endodontics]. Endodontie 2001;10(4):35164.
[6] Ruddle CJ. Cleaning and shaping root canal systems. In: Cohen S, Burns RC, editors.
Pathways of the pulp. 8th edition. St. Louis: CV Mosby; 2001. p. 23191.
[7] Yared GM, Bou Dagher FE, Machtou P. Inuence of rotational speed, torque and
operator prociency on ProFile failures. Int Endod J 2001;34:4753.
[8] Yared GM, Bou Dagher FE, Machtou P, Kulkarni GK. Inuence of rotational speed,
torque and operator prociency on failure of greater taper les. Int Endod J 2002;35:712.
[9] Gambarini G. Cyclic fatigue of ProFile instruments after prolonged clinical use. Int
Endod J 2001;34:3869.
[10] Ruddle CJ. The ProTaper endodontic system. Endod Prac 2002;5(1):3444.
[11] Peters OA, Peters CI, Schoneberger K, Barbakov F. ProTaper rotary root canal
preparation: eects of canal anatomy on nal shape analyzed by microCT. Int Endod J
2003;36:8692.
[12] Ruddle CJ. Finishing the apical one-third. Endod Prac 2002;5(3):1524.
[13] Peters OA, Peters CI, Schoneberger K, Barbakov F. ProTaper rotary root canal preparation:
assessment of torque and force in relation to canal anatomy. Int Endod J 2003;36:939.
111
[14] Martin B, Zelada G, Varela P, Bahillo JG, Magan F, Ahn S, et al. Factors inuencing the
fracture of nickel-titanium rotary instruments. Int Endod J 2003;36:2626.
[15] Zelada G, Varela P, Martin B, Bah llo JG, Magan F, Ahn S. The eect of rotational speed
and the curvature of root canals on the breakage of rotary endodontic instruments. J Endod
2002;28:5402.
[16] Yared GM, Bou Dagher FE, Machtou P. Cyclic fatigue of ProFile rotary instruments after
simulated clinical use. Int Endod J 1999;32:1159.
[17] Pruett JP, Clement DJ, Carnes DL. Cyclic fatigue testing of nickel-titanium endodontic
instruments. J Endod 1997;23:7785.
[18] Schilder H, Yee FS. Canal debridement and desinfection. In: Cohen S, Burns RC, editors.
Pathways of the pulp. 3rd edition. St. Louis: CV Mosby; 1984. p. 175.
[19] Bergmanns L, Van Cleynenbreugel J, Beullens M, Wevers M, Van Meerbeeek B,
Lambrechts P. Progressive versus constant tapered shaft design using NiTi rotary
instruments. Int Endod J 2003;36:28895.
[20] Berutti E, Chiandussi G, Bavaglio I, Ibba A. Comparative analysis of torsional and
bending stresses in two mathematical models of nickel-titanium rotary instruments:
ProTaper versus Prole. J Endod 2003;29:159.
114
Fig. 1. Overview of a LightSpeed instrument (left) with its short cutting head and thin
noncutting taperless shaft compared with a K-FlexoFile (Dentsply-Maillefer, Ballaigues,
Switzerland) (right) with its 16-mm-long cutting surface.
Sizes
A set of LightSpeed instruments totals 26 and encompasses sizes 20 to
140; the instruments are marketed in lengths of 21 mm, 25 mm, and 31 mm.
In addition to the color-coded full ISO sizes, LightSpeed instruments also
have half-sizes, placing sizes 22.5, 27.5, 32.5, respectively, between sizes 20
and 25, between sizes 25 and 30, and between sizes 30 and 35. The last two
half-sizes are sizes 57.5, and 65, which t between sizes 55 and 60 and
between sizes 60 and 70, respectively. The half-sizes are color-coded exactly
as the previous size, but also have white or black markings or engraved rings
on the instruments handles. These markings or rings are important, because
it is impossible to identify the full size from its corresponding half-size by
color alone.
Cutting heads
LightSpeed cutting heads are designed to operate in a continuous
clockwise rotation and have three radial lands and three U-shaped spiral
115
grooves between the radial lands. Although cutting surfaces of most enginedriven instruments are 16 mm long, the smallest (size 20) and largest (size
140) LightSpeed cutting heads are 0.25 mm and 2.25 mm long, respectively.
In addition, LightSpeed is the only rotary system whose cutting heads have
three dierent geometric shapes (Fig. 2). The rst ve LightSpeed
instruments (sizes 20 through 30) have short, noncutting pilot tips and
a 75-degree cutting angle. Instrument size 32.5 is a transition instrument
with a slightly longer noncutting pilot tip and a 33-degree cutting angle. All
other instruments (sizes 35 through 140) have longer and more slender
noncutting pilot tips than do the transitional instrument and a 21-degree
cutting angle. The major dierences between LightSpeed instruments and
conventional stainless steel and nickel-titanium hand les are summarized
in Table 1. Cutting heads of all LightSpeed instruments terminate in
noncutting pilot tips (Fig. 3). The spiral grooves help to transport debris
coronally, whereas the radial lands and noncutting pilot tips help rotating
LightSpeed instruments to remain better centered in canals (Fig. 4).
Thin shafts
LightSpeed is the only rotary system whose instruments have thin,
taperless, noncutting shafts. This design maximizes the exibility of nickeltitanium and enables instruments to negotiate primary, secondary, and
tertiary curves in both the bucco-lingual and mesio-distal planes. Fig. 5
illustrates a cross-section, 1.5 mm from the root apex, showing dierent
parts of two cutting heads in two canals with dierent working lengths. In
one canal, the noncutting pilot tip is sectioned, whereas in the other, the
radial lands and spiral grooves are sectioned.
Fig. 2. SEM photomicrograph of three LightSpeed cutting heads showing dierences between
sizes 20 (top), 32.5 (right), and 40 (left) and the radial lands and spiral grooves (original
magnication 40).
116
Table 1
Dierences between LightSpeed instruments and conventional stainless-steel endodontic les
Metal/alloy
Shaft diameter
Length of cutting head (mm)
Tip angles
Noncutting pilot tip
Tip design constant
Intermediate sizes
Tolerance
Smallest size
Largest size
a
b
c
LightSpeed instruments
Nickel-titanium
0.16 to 0.51 mm
0.25 (20) to 2.25 (140)
Varies; 21, 33, and 75 degrees
Yes
No
Yes
0.005 mmc
20
140
Stainless steel
Increases linearly
16 size
Similar for all les
Noa
Yes
Nob
0.02 mm
08
140
Fig. 3. SEM photomicrograph of a LightSpeed cutting head showing the noncutting pilot tip,
radial lands, spiral grooves, and part of the taperless shaft in an unusual perspective (original
magnication 200).
117
Fig. 4. Front and back of a LightSpeed cutting head showing dentin debris lling spaces
between radial lands.
Fig. 5. Root apices of a maxillary rst premolar with the LightSpeed MAR instruments xed in
situ and cross-sectioned 1.5 mm from the tip showing the noncutting pilot tip and the cutting
blades in the two canals. Working length is dierent in the two canals (original magnication
64, scale 0.5 mm).
118
119
master apical rotary (MAR), and the nal rotary (FR) [7]. The IAR is
dened as the rst LightSpeed instrument, which begins to cut canal walls at
the working length, whereas the MAR is the last instrument to form the
apical preparation. The MAR may be 6 to 12 LightSpeed sizes larger than
the IAR. The FR is the last step-back instrument and completes the stepback procedure.
The Zurich LightSpeed technique is divided into four steps. Step 1
constitutes the access and coronal prearing, step 2 determines working
length and the IAR, step 3 determines the MAR, and step 4 completes the
step-back and recapitulation.
Step 1: Access and coronal prearing
After the canal orices are located, their diameters are enlarged in a stepdown or crown-down procedure using Gates-Glidden burs (GGBs;
Dentsply Maillefer), progressing from large to small sizes [11,12]. In shorter
canals, two GGBs may suce; in longer canals, three or four GGBs may
be indicated. Each GGB advances only 1 mm to 1.5 mm into the canal,
enlarging no more than the coronal 4 mm to 6 mm. It is important to follow
the roots long axis and oval canals can be milled readily with the GGBs.
The step-down procedure or prearing removes signicant amounts of
necrotic tissue and microorganisms from the canal coronally.
Step 2: Determine working length and IAR
After prearing, the working lengths are determined for each canal using
at least size 15 stainless steel K-Files; this is veried radiographically or
electronically. LightSpeed instruments are used from this point on,
beginning with size 20; the aim is to reach the working length. The rst
few LightSpeed instruments used may not ream the canal walls because the
canals are too large; these instruments are termed nonbinding instruments. Nevertheless, always begin with size 20, sequentially progressing to
larger sizes without skipping a single size. Nonbinding instruments advance
in steps of 1 mm to 2 mm to the working length with slow, controlled
movements. Eventually, one LightSpeed instrument will start to cut the
canal walls at working length; this instrument is designated the IAR.
Step 3: Determine MAR
All LightSpeed instruments used after the IAR are called binding
instruments. They are used with controlled forward (1 mm to 2 mm) and
backward (2 mm to 4 mm) pecking movements. The forward motion
reams the canal, whereas the backward motion tends to clean the cutting
head as it retreats into fresh irrigant. These instruments also are used
sequentially from smaller to larger sizes, each advancing with the pecking
movements. The diameter of the apical preparation increases with each
instrument that reaches working length. The last instrument used to form
120
MAR size
70
60
60
60
50
40
50
40
50
60
60
80
60
50
40
50
40
50
121
Finally, all canals are recapitulated once with using their respective MARs
to working length. Figs. 6 through 9 detail four molars that were
endodontically treated by general practitioners using the Zurich LightSpeed
technique.
The Zurich LightSpeed technique can be combined readily with currently
marketed tapered rotary systems. This procedure calls for .04 or .06 tapered
system to be used according to the manufacturers instructions, but only
until the size 20 instrument completes the crown-down mode. From this
Fig. 6. (A) Working length radiograph of a mandibular second molar scheduled for LightSpeed
preparation using the Zurich technique (February 11, 1997). Note the apical periodontitis on
the mesial and distal root apices (case supplied by Dr. A. Bindl). (B) Final ll radiograph
(lateral condensation) of the mandibular second molar (Fig. 6A) prepared with LightSpeed
instruments (May 27, 1997). MAR in all canals was size 50. Both apical radiolucencies are
resolving (case supplied by Dr. A. Bindl). (C) Thirty-month follow-up radiograph of the
mandibular second molar shown in Fig. 6A with a Cerec (Sirona, Bensheim, Germany)
restoration and healed apical areas (January 28, 2002; case supplied by Dr. A. Bindl).
122
Fig. 6 (continued )
point, the apical and middle thirds of the canal (5 mm to 8 mm) are
completed using LightSpeed instruments as described above.
Manufacturers recommended LightSpeed technique
The manufacturers recommended technique states that before beginning
instrumentation with LightSpeed, a straightline access should be made, the
canal should be ared coronally with any instrument such as GGBS (not
LightSpeed), the working length should be determined, and canal patency
should be achieved with at least a size 15 K-type le [13]. Pulp tissue should
be removed with broaches when possible and then LightSpeed instruments
are used to complete canal preparation in the ve steps described below.
Step 1: Determine the LightSpeed size that is used to begin rotary
instrumentation (sizing or gauging the apical canal diameter)
This step determines the smallest canal dimension from the canal orice
to the working length, and which LightSpeed instrument begins the
instrumentation. The sizing process (gauging) avoids wasting time using
LightSpeed instruments that are too small for the canal and provides
valuable information about preinstrumentation canal sizeinformation
that is critical to prevent the underpreparation of canals.
To gauge (size) with LightSpeed instruments correctly they must be used
by hand, advancing apically using moderate pressure but never rotated. The
concept of gauging or sizing is as follows. A LightSpeed instrument can
reach working length if its cutting head is smaller than the canals diameter
from orice to working length. For example, a size 25 LightSpeed that goes
to working length indicates that the canals diameter is larger than the size
25 instrument. Gauging continues with sequentially larger sizes until
a LightSpeed instrument does not go to working length. Continuing with
123
Fig. 7. (A) Radiograph of the nal ll (lateral condensation) of four canals in a maxillary rst
molar prepared with LightSpeed instruments using the Zurich technique (December 12,
1996). MAR in the four canals was size 47.5 (case supplied by Dr. A. Bindl). (B) Five-year
follow-up radiograph of the maxillary rst molar shown in Fig. 7A (February 24, 2003). MAR
in all four canals was size 47.5 (case supplied by Dr. A. Bindl).
the above example, if size 25 reaches working length but size 27.5 does not,
then size 27.5 is called the First LightSpeed Size to Bind (FLSB). The FLSB
is placed in the handpiece to begin rotary instrumentation.
Step 2: Determine the apical preparation size
Start instrumenting with the FLSB using a slow, continuous movement,
advancing cautiously until it engages the canal walls. At this point,
immediately stop advancing, pause for a fraction of a second, and then
progress apically with an advance and withdrawal motion (pecking). This
pecking movement translates into a downward cut of the dentin followed
124
Fig. 8. (A) Working length radiograph of a mandibular second molar scheduled for
preparation with LightSpeed instruments using the Zurich technique (November 1994).
Note the endo-perio lesion adjacent to the distal root (case supplied by Dr. J. Zafran). (B)
Eighteen-month follow-up radiograph of the mandibular second molar shown in Fig. 8A (April
1996) obturated with ThermaFil. MAR in the two mesial canals and one distal canal were sizes
42.5 and 50, respectively. Note the healed endo-perio lesion adjacent to the distal root (case
supplied by Dr. J. Zafran).
125
Fig. 9. (A) Final ll radiograph (ThermaFil) of a mandibular second molar prepared with
LightSpeed instruments using the Zurich technique (November 1994). MAR in the two
mesial canals and one distal canal were sizes 42.5 and 50, respectively (case supplied by Dr. J.
Zafran). (B) Fifteen-month follow-up radiograph of the mandibular second molar shown in
Fig. 9A (February 1996; case supplied by Dr. J. Zafran).
MAR. This is called the 12 pecks rule. Canals with naturally large or
small sizes will have larger- or smaller-sized MARs, respectively. The size of
the MAR depends on the preinstrumentation canal size, which varies from
tooth to tooth. There is no such thing as a given canal size for each tooth in
the mouth.
Step 3: Complete apical instrumentation
After determining the MAR size with the 12 pecks rule, complete the
apical preparation by using the very next LightSpeed size that is 4 mm
shorter than the working length. This enables the 5-mm long SimpliFill GP
126
Plug (LightSpeed Endodontics) to closely match the size and shape of the
canal preparation. However, if obturating with standardized GP cones, step
back 4 mm with sequentially larger LightSpeed instruments so that each
length is 1 mm shorter than the previous instrument. This prepares the
apical 5 mm of the canal with a taper matching that of a standardized cone.
Step 4: Instrument mid-root
If obturating with SimpliFill, continue instrumenting the middle 4 to 5
mm of the canal only with sequentially larger full size (skip half-sizes)
LightSpeed instruments. Use the same pecking motion described in step 2
until a LightSpeed instrument no longer advances easily. Continue this
process with sequentially larger LightSpeed full sizes until reaching a size
that cannot advance easily past the apical extent of the coronal third of the
canal. Do not allow any mid-root instrument to enter the apical 5 mm.
However, if obturating with standardized GP cones, do not skip half-sizes
during the mid-root preparation. Continue the step-back from working
length in 1-mm increments until reaching a LightSpeed size that is at least
25 larger than the MAR. For example, if the MAR is a size 40, step back in
1-mm increments to at least a size 65.
Step 5: Recapitulate
Recapitulate to the working length of each canal with the respective
MAR. The MAR is the instrument that required at least 12 pecks to reach
working length (step 2).
LightSpeed technique combined with taper technique
LightSpeed Endodontics recommends this hybrid technique for clinicians
wishing to combine both tapered rotary and LightSpeed systems. In this
way, canals can be cleaned and shaped in a crown-down fashion according
to the technique recommended by the manufacturer of the tapered instruments used. After the crown-down is completed, LightSpeed instruments
complete the apical part of the canal [8]. The hybrid technique assumes that
the canal has rst been instrumented to working length with .04 or .06
tapered rotary instruments with a tip size 25 using the manufacturers recommended technique. Then, LightSpeed instruments are used to complete
the apical preparation.
Step 1: Apical gauging
Follow the concept of apical gauging described in step 2 of the
manufacturers recommended LightSpeed technique. With the combined
technique, always start the gauging process by hand with a size 35
LightSpeed instrument, without rotating it and using moderate force. After
entering the canal, advance the instrument apically and one of three things
will occur:
127
Discussion
This article discusses three ways to use LightSpeed instruments. Purists
may contend that the manufacturers recommended technique always should
be followed to the letter. Although some clinicians may do just that, others
modify the methods that they have learned at courses on LightSpeed or other
nickel-titanium rotary techniques. Consequently, two of the three techniques
in this article describe using LightSpeed instruments alone and one describes
the combined use of LightSpeed with tapered rotary instruments. Although
using two rotary techniques has advantages, some clinicians complain about
combining two systems and the related increased costs. Nevertheless, the
three techniques are described to give experienced and nonexperienced users
pointers on how LightSpeed instruments may be used.
Generally, LightSpeed instruments enable larger apical preparations
because their design maximizes the exibility of nickel-titanium more so than
do other rotary instruments currently available, particularly for the larger
sizes. Independent studies performed since 1995 [1421] indicate that LightSpeed instruments produce better-centered apical preparations compared
with other les or instruments. For example, apical preparations in mesial
canals of mandibular molars produced little or no apical transportation
when prepared by LightSpeed instruments [14], even when canals were
128
129
Fig. 10. Photomicrograph (original magnication 215) showing metal strip on the noncutting
pilot tip of a size 37.5 LightSpeed instrument used clinically in 20 canals. (Modied from
Marending M, Lutz F, Barbakow F. Scanning electron microscope appearance of Lightspeed
instruments used clinically: a pilot study. Int Endod J 1998;31(1):60; with permission.)
Fig. 11. Photomicrograph (original magnication 90) of a disrupted edge and metal ash of
radial lands of a size 50 LightSpeed instrument used clinically in 20 canals. (Modied from
Marending M, Lutz F, Barbakow F. Scanning electron microscope appearance of Lightspeed
instruments used clinically: a pilot study. Int Endod J 1998;31(1):60; with permission.)
130
Summary
LightSpeed instruments, with their short cutting heads, noncutting pilot
tips, and long thin taperless shafts, are unique in their design. The
instruments maximize the exibility of nickel-titanium, particularly for the
larger sizes. Consequently, they enable larger apical preparations without
overpreparing the coronal canal thirds. By so doing, better mechanical
removal of necrotic debris and microorganisms may be possible. With larger
canal spaces, more disinfecting irrigants can reach the apical areas and may
ensure a better disinfection.
131
Fig. 12. (A) Radiograph showing a fracture in the shaft-shank area of a LightSpeed
instrument in the disto-buccal canal of a maxillary rst molar (case supplied by Dr. N. Gabutti).
(B) Final ll radiograph of the tooth shown in Fig. 12A following removal of the fractured
LightSpeed segment from the disto-buccal canal (case supplied by Dr. N. Gabutti).
132
133
Donts
1. Dont force LightSpeed
instruments
2. Dont use LightSpeed
instruments in
dry canals
3. Dont exceed a speed
of 2000 rpm
4. Dont linger at a point when
the working length has
been reached
5. Dont vary the speed while
instruments are rotating in
the canal
6. Dont use LightSpeed
without rubber dam
7. Dont overuse LightSpeed
instruments
Acknowledgments
The author thanks many people who helped compile this manuscript
including Andi Bindl, Nick Gabutti, Peter Velvart, and Jakob Zafran
for allowing the author to present their LightSpeed cases and Liselotte
Brandenberger, Beatrice Sener, and Anna-Lise Teuscher for preparing the
photographic material. A nal word of thanks goes to Syngcuk Kim and
b
Fig. 13. (A) Radiograph showing a fractured LightSpeed instrument in a mesial canal of
a mandibular second molar (case supplied by Dr. P. Velvart). (B) View of the fractured surface
of a LightSpeed shaft seen through an operating microscope and the retrieved instrument after
removal using ultrasonics (case supplied by Dr. P. Velvart). (C) Radiograph conrming
retrieval of the fractured LightSpeed segment shown in Fig. 13A (case supplied by Dr. P.
Velvart). (D) Final ll radiograph after retrieving the fractured segment shown in Fig. 13A (case
supplied by Dr. P. Velvart).
134
John Vassallo for their patience and understanding. All these names prove
yet again that no man is an island to himself.
References
[1] Ingle JI, Bakland LK, Peters DL, Buchanan LS, Mullaney TP. Endodontic cavity
preparation. In: Ingle JI, Bakland LK, editors. Endodontics. 4th edition. Baltimore:
Williams & Wilkins; 1994. p. 92227.
[2] Roane JB, Sabala CL, Duncanson MG. The balanced force concept for instrumentation
of curved canals. J Endod 1985;11(5):20311.
[3] Walia HM, Brantley WA, Gerstein H. An initial investigation of the bending and torsional
properties of nitinol root canal les. J Endod 1988;14(7):34651.
[4] Wildey WL, Senia ES. A new root canal instrument and instrumentation technique:
a preliminary report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1989;67(2):
198207.
[5] Peters O, Eggert C, Barbakow F. Aufbereitung gekrummter Wurzelkanale unter
Anwendung der Lightspeed-Methode, Teil 1. [Preparing curved root canals using the
Lightspeed method. Part 1: basic principles.] Grundlagen. Endodontie 1997;6(4):26772.
[6] Eggert C, Peters O, Meyer E, Barbakow F. Aufbereitung gekrummter Wurzelkanale unter
Anwendung der Lightspeed-Methode, Teil 2. Praktische Anwendung. [Preparing curved
root canals using the Lightspeed method. Part 2: practical procedure.] Endodontie 1998;
7(1):3140.
[7] Peters O, Eggert C, Barbakow F, Lutz F. Wurzelkanalpraparation mit LightspeedInstrumenten. Klinische Anwendung manual. [Root canal preparation using Lightspeed
instruments hands-on manual.] Zurich: Verlag PPK; 1997. p. 1438.
[8] Senia ES, Wildey WL. LightSpeed technique guide, instrumentation. Available at: http://
www.LightSpeed.com. Accessed July 28, 2003.
[9] Senia ES. Canal diameter: the forgotten dimension. Endod Prac 2000;3(2):349.
[10] Machtou P, Martin D. Advances in rotary instrumentation sequences. Endod Prac 2000;
3(2):2833.
[11] Goerig AC, Michelich RJ, Schultz HH. Instrumentation of root canals in molars using the
step-down technique. J Endod 1982;8(12):5504.
[12] Morgan LF, Montgomery S. An evaluation of the crown-down pressureless technique.
J Endod 1984;10(10):4918.
[13] Senia ES, Wildey W. Straightline access guide. Available at: http://www.lightspeedusa.
com/techniqueguide.html. Accessed July 28, 2003.
[14] Glossen CR, Haller RH, Dove SB, del Rio CE. A comparison of root canal preparations
using Ni-Ti hand, Ni-Ti engine-driven and K-Flex endodontic les. J Endod 1995;21(3):
14651.
[15] Knowles KI, Ibarrola JL, Christiansen RK. Assessing apical deformation and transportation following the use of LightSpeed root-canal instruments. Int Endod J 1996;29(2):
1137.
[16] Short JA, Morgan LA, Baumgartner JC. A comparison of canal centering ability of four
instrumentation techniques. J Endod 1997;23(8):5037.
[17] Portenier I, Lutz F, Barbakow F. Preparation of the apical part of the root canal by the
LightSpeed and step-back techniques. Int Endod J 1998;31(2):10311.
[18] Deplazes P, Peters O, Barbakow F. Comparing apical preparations of root canals shaped
with nickel-titanium rotary and nickel-titanium hand instruments. J Endod 2001;27(3):
196202.
[19] Shadid DB, Nicholls JI, Steiner JC. A comparison of curved canal transportation with
balanced force versus lightspeed. J Endod 1998;24(10):6514.
[20] Versumer J, Hulsmann M, Schafers F. A comparative study of root canal preparation
using Prole.04 and LightSpeed rotary Ni-Ti instruments. Int Endod J 2002;35(1):3746.
135
[21] Weiger R, Bruckner M, ElAyouti A, Lost C. Preparation of curved root canals with rotary
FlexMaster instruments compared to LightSpeed instruments and NiTi hand les. Int
Endod J 2002;36(7):48390.
[22] Peters OA, Laib A, Ruegsegger P, Barbakow F. Three dimensional analysis of root canal
geometry using high resolution computed tomography. J Dent Res 2000;79(6):14059.
[23] Peters OA, Schonenberger K, Laib A. Eects of four Ni-Ti preparation techniques on root
canal geometry assessed by micro computed tomography. Int Endod J 2001;34(3):22130.
[24] Shuping GB, Orstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using
nickel-titanium rotary instrumentation and various medications. J Endod 2000;26(12):
7515.
[25] Card SJ, Sigurdsson A, Orstavik D, Trope M. The eectiveness of increased apical
enlargement in reducing intracanal bacteria. J Endod 2002;28(11):77983.
[26] Siquiera JF, Rocas IN, Santos SR, Lima KC, Magalhaes FAC, de Uzeda M. Ecacy of
instrumentation techniques and irrigation regimens in reducing the bacterial population
within root canals. J Endod 2002;28(3):1814.
[27] Rollison S, Barnett F, Stevens RH. Ecacy of bacterial removal from instrumented root
canals in vitro related to instrumentation technique and size. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2002;94(3):36671.
[28] Peters OA, Barbakow F. Eects of irrigation on debris and smear layer on canal walls
prepared by two rotary techniques: a scanning electron microscopic study. J Endod 2000;
26(1):610.
[29] Dummer PMH, McGinn JH, Rees DG. The position and topography of the apical canal
constriction and apical foramen. Int Endod J 1984;17(4):1928.
[30] Kerekes K, Tronstadt L. Morphometric observations on root canals of human anterior
teeth. J Endod 1977;3(1):249.
[31] Kerekes K, Tronstadt L. Morphometric observations on root canals of human premolars.
J Endod 1977;3(2):749.
[32] Kerekes K, Tronstadt L. Morphometric observations on the root canals of human molars.
J Endod 1977;3(3):1148.
[33] Gani O, Visvisian C. Apical canal diameter in the rst upper molar at various ages. J Endod
1999;25(10):68991.
[34] Marending M, Lutz F, Barbakow F. Scanning electron microscope appearance of
LightSpeed instruments used clinically: a pilot study. Int Endod J 1998;31(1):5762.
[35] Eggert C, Peters O, Barbakow F. Wear of nickel-titanium LightSpeed instruments
evaluated by scanning electron microscope. J Endod 1999;25(7):4947.
138
7. A variable ute pitch (Fig. 8). This feature also helps prevent the
screwing-in eect common with some brands of les and promotes
debris removal.
8. Color coding to distinguish between dierent tip sizes and tapers
(Fig. 9).
9. A safe-ended cutting tip (Fig. 10).
10. K3 body shaper les with an enhanced taper of 0.08, 0.10, and 0.12
that can act as both canal shaping les, orice openers, and deep body
Fig. 2. The availability of K3 canal shaping les with regard to taper, tip size, and length.
139
Fig. 3. The K3 has a positive rake angle, providing a more eective cutting edge (SybronEndo).
shaping les (these are available in a xed tip size of 25 and in 17-, 21-,
and 25-mm lengths) (Fig. 11). These body shapers have a modied design
relative to the 0.02, 0.04, and 0.06 tapered K3 les. The body shapers
have a shorter taper length (the apical 8 mm, which provides the cutting
function to the le), allowing for a smaller maximum diameter at the
shank and creating a more exible instrument. The uting on the straight
(nontapered) shank is not designed to cut eectively and the straight
Fig. 4. The K3 has a variable core diameter, which increases exibility over the entire cutting
length.
140
Fig. 5. (AC) In cross-section, the K3 has a series of three wide radial lands to keep the le
centered, with a relief behind two of the lands. The feature reduces friction on the canal wall and
prevents the le from overengagement.
shank section does not have relieved radial lands. The remaining utes
are parallel so as to increase le exibility and optimize the rate at which
the le can be introduced into the canal. By design, the K3 body shapers
channel debris away from their tips, which can mean somewhat less
required recapitulation, less cutting time, and decreased fracture rates.
Like the original K3 les, the tapered region of the body shapers utes
are relieved at the distal of their radial lands to reduce peripheral surface
contact, enhancing performance. Generally, these les are rotated at 350
rpm. The K3 body shapers have a slightly dierent helix angle relative to
the other K3 sizes and tapers to make them cut more smoothly.
141
Fig. 5 (continued )
Fig. 6. The K3 (right panel) has asymmetrically placed radial lands of unequal width and
unequal ute widths and depths that aid in preventing the le from screwing into the canal. In
contrast, U-shaped les (left panel) have symmetrical attributes that promote screwing in,
increasing the risk of separation.
142
It also has excellent cutting ability. The le cuts dentin eectively, yet does
not pull itself into the canal apically.
The K3 can be used more than once in all tapers, especially above a tip
size of 25. How many times a le can be used before it is discarded is a matter
of clinical judgment (see the later section on Assumptions for K3 clinical
technique). The K3 will bend out of straight alignment when used beyond
its elastic limit and should be discarded with this occurrence and with
the presence of wear marks. This ability to bend is a unique feature not
possessed by other commercially available brands.
The 17-mm body shapers have the greatest universal applicability. The
25-mm K3 canal shaping instruments are easier to visualize under the
surgical operating microscope due to the Axxess handle. The 25-mm K3 les
are easy to use and visualize even with patients of limited opening and
access.
The K3 instruments are more than adequately exible. Their tactile sense
of rigidity or stiness in hand has no clinical correlation. The 0.02 and
Fig. 8. The K3 has a variable ute pitch to reduce the screwing in eect common with some
brands of rotary nickel titanium les.
143
Fig. 9. The K3 has simple color-coding to distinguish between dierent tip sizes and tapers.
0.04 tapered K3 les in the smallest tip sizes (1520) make excellent tracking
les as an aid to helping create and/or accentuate a glide path. Specically,
after a glide path has been established to a size 10 K le, for example, the
0.02 and 0.04 size 15 le will generally slide close to true working length and
create eciencies with regard to insertion of subsequent les. Because the
K3 tracks the canal easily, it moves smoothly down the root to accentuate
the initial shapes created by hand in the preparation of the glide path.
Literature
Because of the relatively recent introduction of the K3 into the
marketplace and despite its widespread popularity, there is limited literature
available.
Bergmans and colleagues [1], using microfocus CT, concluded that in
extracted teeth, the ProTaper (Dentsply Tulsa Dental, Tulsa, Oklahoma)
and the K3 were capable of preparing canals with optimum morphological
characteristics in curved canals. In addition, the amount of dentin
removal at all separate horizontal regions was comparable for both groups.
There was no signicant dierence in transportation between the two groups
and with regard to their tendency to straighten the canal.
144
Fig. 11. K3 body shaper les with enhanced taper of 0.08, 0.10, 0.12 that can act as both
canal shaping les, orice openers, and deep body shaping les (these are available in a xed tip
size of 25 and in 17-, 21-, and 25-mm lengths (SybronEndo).
145
Fig. 12. (A, B) The K3 has excellent fracture resistance. Removal of separated rotary nickel
titanium les is an ultrasonic microscopic procedure as illustrated.
with the K3 in daily clinical practice, the K3, for the most part, is dicult to
fracture and will do so only if used after it has acquired deformations (an
indication for being discarded) or a signicant amount of undue force is
placed on it. It is possible that the performance characteristics of the K3 in
resin bear no resemblance to those in human teeth and that the master
apical rotary size used in the study (size 35) is larger than that most
commonly employed in clinical practice. Also, rotating the les at 250 rpm
may also have contributed to this nding instead of at the recommended 350
rpm.
146
a K3 apically that resists movement. Pull back at the rst sign of undue
resistance in the canal. The motion in entering the K3 into the canal
should be slow, gentle, smooth, and deliberate and in approximately 1to 2-mm deeper increments relative to the last instrument.
Frequent irrigation with 5.25% sodium hypochlorite is desirable. An
average molar tooth might optimally require 72 to 144 cc of irrigant
delivered with a close-ended, side-venting needle. The longer the irrigant
is in contact with the canal, the more eective its tissue dissolving
capability, especially in the apical third. EDTA or sodium hypochlorite
(or both) should be in the canal or canals at all times. Failure to do so
(instrumenting dry) can create a plug of apical dentin mud and increase
the risk of transportation or instrument fracture. EDTA should be used
from the start in all vital cases and can emulsify and hold the pulp in
suspension until its removal by way of irrigation. Failure to do so can
create a collagenous mass of pulp that can be pumped irretrievably into
the narrowing cross-sectional diameters of the root canal system, often
with iatrogenic results.
Removal of the smear layer present after instrumentation is desirable.
Rinsing or soaking the canal with liquid EDTA (SmearClear,
SybronEndo) after a nal sodium hypochlorite irrigation is optimal.
SmearClear includes surfactants that reduce surface tension and allow
maximum wetting of the canal walls for greatest ecacy (Fig. 13).
Patency is maintained. Patency refers to the deliberate attempt to keep
the minor constriction of the apical foramen open during instrumentation procedures so as to block the apex with dentin mud, move the canal
from its original position, or change the foramens original size and
shape. Dentin mud includes pulp and dentin debris from instrumentation that can plug the apical foramen and prevent negotiation to the
constriction mentioned previously. Patency is important primarily
because its loss causes signicant debris to remain harbored in the
canals apical third (predisposing the case to failure), and blockage can
be a major factor in causing iatrogenic events (most commonly ledging
and separated instruments). Patency is most often obtained by using
small K le sizes of 6 to 15 after every rotary le just slightly (usually 1
mm) out the apical foramen to make sure that the canal path is clear to
its most apical extent. In some calcied and curved roots, it may be
necessary to irrigate and recapitulate after every K3 insertion to keep the
foramen open (Fig. 14).
Crown down instrumentation is desirable. Crown down instrumentation implies that the coronal third is instrumented rst, the middle third
second, and apical third last (Fig. 15). Using the K3 from larger to
smaller tips sizes (of the same or varying taper) incorporates crown
down instrumentation as each successively smaller le progresses
further down the canal passively. K3 les and the body shapers can
be taken to the true working length and used as the master apical le,
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Fig. 13. Removal of the smear layer with liquid EDTA (SmearClear, SybronEndo) after nal
irrigation with sodium hypochlorite is optimal.
148
Fig. 14. Patency is important primarily because its loss causes signicant debris to remain
harbored in the canals apical third (predisposing the case to failure), and blockage can be
a major factor in causing iatrogenic events (most commonly, ledging and separated
instruments). (Courtesy of Arnaldo Castelucci, DDS, Florence, Italy.)
K3 clinical technique
Coronal-third and middle-third management
Before making access, it is essential to radiograph the tooth from
multiple angles including mesial, straight buccal, and distal. Preoperatively,
an assessment of the number of roots, canal curvature, length of tooth,
149
Fig. 15. Crown down instrumentation is desirable. Crown down instrumentation implies that
the coronal third is instrumented rst, the middle third second, and apical third last. The
diagramed instrumentation sequence ensures a crown down technique.
150
Fig. 16. It is recommended to use an electric torque control motor with auto reverse to power
the les at the correct rpm. The TCM Endo III motor (SybronEndo) is such a device. Clinically,
most manufacturers have endorsed a rotational speed of approximately 300 to 350 rpm for
maximum eciency.
151
Fig. 17. (A) Before making access, it is essential to radiograph the tooth from multiple angles
(only the straight buccal is shown). (B, C) Subsequent treatment with the K3 system.
152
Fig. 18. Deep body shape is a key component of achieving control over subsequent apical-third
instrumentation and obturation. (A) A lack of deep body shape. (B) Subsequent retreatment
and its attainment.
(or the appropriate body shaper) will not progress to the desired level (the
junction of the middle and apical third), then a 0.06 K3 with a tip size of 30,
25, 20, or 15 can be employed instead. Recapitulation and irrigation should
be frequent as described earlier, ideally after every le.
Apical-third management and deep body shape
The apical third is the most challenging root canal anatomy to cleanse,
shape, and pack properly. Instrumenting the apical third rst, without
removing restrictive dentin in the more coronal two thirds, risks apical
blockage, underpreparation, and iatrogenic misadventure, among other less
than satisfactory outcomes. Coincident to the importance of crown down
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154
Fig. 20. K3 les are introduced in a crown down fashion with a sequence that either (A) varies
the tip size (with subsequently smaller K3 tip sizes) or (B) varies the taper (mixing the tapers of
the instruments as the tip size diminishes). ETBS, enhanced tapered body shapers.
155
Fig. 21. The nal shape imparted to the canal by a given K3 le can be matched by a gutta
percha point (A) and a paper point (B) of the same taper (Autot gutta percha and paper
points, SybronEndo).
156
percha and paper points, SybronEndo) (Fig. 21). A paper point of the
appropriate taper, if it will slide to length without deformation (after the
canal is dry), informs the operator of the actual taper of the prepared canal
and simplies cone t. A cone-t radiograph with the gutta percha point in
place before obturation conrms working length and appropriate preparation shape and is strongly recommended to assure the best results, even with
the information gained by way of the paper points used as detailed earlier.
These steps also facilitate subsequent obturation with the continuous wave
of condensation obturation technique (System B obturation with the System
B heat source, SybronEndo). After a cone-t radiograph and usually minor
adjustments, excellent obturation is possible for a multirooted molar in
a matter of minutes without the necessity of leaving a carrier as required in
carrier-based obturation techniques.
Fig. 22. The hybrid technique. The K3 rotary nickeltitanium le system is used for coronalthird and middle-third shaping and the initial exploration of the apical third (A), whereas
LightSpeed rotary les are used for the nal apical preparation (B).
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irrigation, ease of cone t, and cleaner canals in the apical third by virtue of
the dentin and pulp removed at that level. The smooth shaft of the
LightSpeed les facilitates their use deep in canals with greater ease than
many other brands of rotary nickeltitanium les. Although the use of
LightSpeed les is detailed elsewhere in this issue, it is noteworthy that
before the employment of LightSpeed les to create a larger nal apical
diameter, the K3 should be taken to true working length, generally in a tip
size of 25 and taper of 0.06 (Fig. 22).
Summary
The K3 rotary nickeltitanium le system by SybronEndo is a state-ofthe-art rotary nickeltitanium endodontic instrumentation method that
combines excellent cutting characteristics with a robust sense of tactile
control and excellent fracture resistance. Although it is a complete instrumentation system, future possibilities for hybrid instrumentation techniques that combine the best features of K3 with other rotary systems (most
notably the LightSpeed) hold promise.
Acknowledgement
The author would like to thank Gary Carr, Pacic Endodontic Research
Foundation, Excellence in Endodontics 2, and the Digital Oce Program
for Endodontists.
References
[1] Bergmans L, Van Cleynenbreugel J, Beullens M, Wevers M, Van Meerbeek B, Lambrechts
P. Progressive versus constant tapered shaft design using NiTi rotary instruments. Int
Endod J 2003;36(4):28895.
[2] Shafer E, Florek H. Eciency of rotary nickel-titanium K3 instruments compared with
stainless steel hand K-Flexole. Part 1. Shaping ability in simulated curved canals. Int
Endod J 2003;36:199207.
Real World Endo, The Barba Plaza, 2nd Floor, 2114 Silverside Road,
Wilmington, DE 19810-4448, USA
b
The Johns Hopkins Hospital, Baltimore, MD, USA
The past 10 years has been witness to many changes in endodontics, and
this trend will continue in the foreseeable future. The introduction of new
technologies has resulted in endodontics becoming easier, faster, and most
important, better. Paramount among these changes has been the introduction of nickeltitanium (NiTi) rotary instrumentation that results in
consistent, predictable, and reproducible shaping. This predictability of
shaping has not only inuenced instrumentation but also obturation results.
Primary cone t no longer needs to be a struggle. Machined, predictable
shaping now makes a primary cone t easy and precise. These changes are
certainly welcomed, but are there more advances on the horizon?
As previously mentioned, the authors are condent that signicant
change will continue to come to endodontics. The anticipated changes range
from the idea of disposable endodontic products to the concept of a true
hermetic seal when obturating the canal. Certainly not the least among the
changes is the issue of making endodontics not only better but also simpler.
The authors rmly believe that the more sophisticated a concept, the simpler
it should be.
As a result of this quest for a better, simpler technique, Real World Endo
in partnership with Brasseler USA has developed a new endodontic le and
sequence. It is hoped that this le and sequence will satisfy many of the
current demands of modern root canal therapy, while at the same time, be
user friendly. Before the specics of this new sequence le are discussed,
however, the benets of a fully tapered preparation must be reviewed.
When clinicians understand the rationale of a continuously tapered 0.06
preparation and perform it in a consistent manner, they will be stunned by
how quickly endodontics can become simpler and more predictable.
Real World Endo has been and continues to be a strong proponent of
a fully tapered 0.06 preparation. There are multiple benets to be gained
* Corresponding author. 23 Misty Meadow, Irvine, CA 92612.
E-mail address: HK5DENT@aol.com (K.A. Koch).
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.11.004
160
from such a preparation. Before the authors evaluate the potential benets,
however, the issue of taper must be addressed.
A question that clinicians often ask is How am I going to place a 0.06
taper le into a space that I have had problems using a 0.02 taper? Isnt
a 0.06 taper le three times the width of a 0.02 taper?
The answer to the above question is no. A 0.06 taper is not just three
times the width of a 0.02 taper. The proof is in the arithmetic. Consider the
following example:
A size 20, 0.02 taper le (20/0.02) is 0.20 mm at a distance (D) of 1 mm
from the tip (D-1), and at D-10, the diameter is 0.40 mm. This number is
calculated by multiplying the taper (0.02) by the length (10 mm). The apical
tip size at D-1 (0.20) is added to the previously calculated number to get 0.40
mm. When the taper is increased from 0.02 to 0.04, it can be determined that
the width at D-10 for the new le is 0.60 mm. Interestingly, the taper
increased 100% (from 0.02 to 0.04), but the width at D-10 only increased
50% (from 0.40 to 0.60 mm).
If the apical size of the le at D-1 is increased to a size 40 (0.40 mm), the
diameter at D-10 for this le can be calculated to be 0.60 mm. Again, if the
taper is increased from 0.02 to 0.04, the diameter at D-10 for the 40/0.04 can
be determined to be 0.80 mm. So, although the taper increased 100% (from
0.02 to 0.04), the width at D-10 only increased 33.33%. This nding is even
more interesting. But what does this really mean?
It means that the eect of taper is inversely proportional to the apical tip
size; that is, as the size of the le increases, the eect of taper decreases. This
is very signicant because this is why a 0.06 taper rotary le can be used with
minimal problems. In addition, this is why a fully tapered 0.06 preparation
can be performed and still have a conservative preparation.
The knowledge of taper also allows the clinician to understand that there
are basically two ways to perform a root canal. The clinician can use
a sequence of les that employs a common tip size but has varying tapers
(eg, a 20/0.10 le followed successively by a 20/0.08, a 20/0.06, and
eventually a 20/0.04 le). The ProSystem GT employs such a variable taper
sequence, as do a number of other le systems such as Quantec and RaCe
(Brasseler USA, Savannah, Georgia).
A second option is to use a constant-taper le system, with variable tip
sizes (eg, a 35/0.04 followed by a 30/0.04, a 25/0.04, and nally a 20/0.04).
Two le systems that employ a constant taper are the Prole and the K3
(SybronEndo, Orange, California).
The authors agree with others who, in eect, have said that the biggest
obstacle to endodontic success is the step back preparation. The authors
could not agree more, and for the past 2 years, Real World Endo has been
trying to get this point across at lectures and in print. The authors, however,
would like to take this point one step further.
The authors strongly believe in using a constant-taper le sequence such
as a 0.04 or 0.06 taper to shape the root canal preparation. A variable-taper
161
concept, in the authors opinion, does not work nearly as well clinically as it
does on paper. When one thinks about it, a variable-taper sequence is
nothing more than a step back preparation from the opposite end of the
tooth. As a result of better-quality manufacturing, clinicians now have
the ability, with a series of constant-taper les, to create predictable,
reproducible shapes. The variable-taper sequence results in a dierent shape
each time a root canal is done. The result is a lack of reproducibility that will
make obturation more challenging.
A total comprehension of taper is absolutely critical to clinicians interest
in increasing the quality of their endodontics; however, the question
remains, Why do endodontists prefer a continuously tapered 0.06
preparation?
There are a number of reasons for this preference. Two of the major
benets of the 0.06-tapered preparation are a dramatic reduction in
postoperative sensitivity for patients and the ability to have a precise cone
t. This combination leads to predictability, along with increased patient
satisfaction; however, there are other benets associated with a 0.06
preparation.
When performing a continuously tapered 0.06 preparation, the larger
taper removes the tooth structure in the coronal part of the canal that has
a tendency to bind instruments. Consequently, the removal of this tooth
structure results in a dramatic increase in proprioceptive ability. Therefore,
one benet of this technique is more tactile awareness. In addition, the
continuous 0.06 taper allows the irrigation agent to work in a more ecient
manner. How eective is the irrigation agent when a size 20 hand le
can hardly screw to length? It is not very eective; however, with a 0.06
preparation (performed in a crown down manner), the irrigation agent
is getting into the root canal system right from the start. The root canal
should be thought of as a three-dimensional system, with webs, ns, and
anastomoses. The only way these areas can be eectively cleaned is through
the use of an irrigation agent. The irrigation agent has the ability to work
much more eectively in a tapered 0.06 preparation compared with a 0.02 or
0.04 preparation. Canals that are preared with GatesGlidden burs (and
a 0.02 or 0.04 taper) do not do as eective a job with irrigation as a 0.06
preparation. In fact, GatesGlidden burs make a parallel preparation in the
coronal part of the canal. A continuous taper, on the other hand, has superior
hydraulics when it comes to irrigation. Furthermore, ultrasonics are particularly eective in a 0.06 taper preparation due to the continuous taper.
Another aspect of the 0.06 preparation that contributes to patient
satisfaction is the reduction in extruded debris. Quite often when performing
a root canal with hand les, debris is pushed out past the end of the tooth.
In a sense, this inoculates the periapical tissues. The sequelae of this is
increased postoperative sensitivity, if not pain and swelling. By using rotary
les that, by design, pull debris coronally rather than push it in an apical
direction, however, the amount of extruded material can be further reduced.
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163
164
a 0.02 taper may work well in the hands of certain specialists, the authors
believe that using 0.02 taper rotary les is a serious mistake for most
clinicians. A 0.02 taper rotary le is so small and exible that it can easily get
pulled into the small radius curvatures present in the apical third of many
teeth. Small radius curvatures are a common cause of instrument breakage.
If a clinician needs to use a 0.02 taper le, the authors recommendation is to
use a hand le. Real World Endo feels very strongly about this issue because
their goal is to not only make instrumentation more ecient for the clinician
but also maintain safety at all times.
Tip design
Tips have been described as either cutting tips or noncutting tips. Some les
claim to have modied cutting tips or partially active tips. Others have
guiding tips. These claims are all a bit of semantics because a tip can actually
be noncutting at the true tip but may become active before D-1 on the shank.
Nonetheless, the greatest safety cushion is aorded with noncutting tips.
Is there a place for a cutting tip on a rotary le? The answer is yes;
however, cutting tips have a limited indication in endodontics and should be
used only in the hands of an experienced clinician. As previously mentioned,
Real World Endo believes that most dentists are best served using a rotary
le with a noncutting tip. The authors are very condent about that
statement. Although some experienced clinicians may be able to use cutting
tips, the authors believe that they are too aggressive for most practitioners.
There are two serious concerns with a cutting tip. The rst is if the
clinician accidentally goes long (past the end of the tooth). Going long
with a noncutting tip will create a concentric circle at the end of the root.
These spaces are easily lled with a nonstandardized or tapered cone;
however, if the clinician goes long with a cutting tip, when the le is
retracted, an elliptical tear is generally created. This tear is very dicult to
repair and obturate, even for a specialist. Furthermore, a cutting tip on
a nonlanded le, or a le that does not have a self-centering ability, has the
very real possibility of transportation.
Cutting eciency
Cutting eciency of rotary les is an area that has received much
attention in the past few years. The more ecient a rotary le, the less
torque is required. Most manufacturers are attempting to address this
challenge. Rotary les with full radial lands and a neutral rake angle have
modest cutting eciency. Rotary les with a positive rake angle and
recessed radial lands may have seemingly better cutting eciency. Depending on where a rotary le is sectioned, however, the rake angle can, in fact,
be dierent. The entire issue of rake angles continues to be one of
controversy in endodontics.
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166
167
Having discussed the design features of rotary les, in a general sense, the
features of the new Real World Endo Sequence File are specically examined.
Fig. 2. (A) Sequence File with ACPs. (B) Diagrammatic representation of ACPs.
168
There are other signicant features to the ACP design. Because the ACPs,
in combination with a precision tip, keep the le centered in the canal, there
is no need for radial lands. This design change is profound because the lack
of radial lands allows the instrument to be sharper and, consequently, more
ecient. In addition, the lack of radial lands results in a decreased thickness
of metal. The result of less metal is a dramatic increase in exibility.
Clinicians will be amazed at how exible a fully tapered 0.06 rotary le can
be when not burdened by the excessive metal that is needed for radial lands.
Metal treatment
Another admirable feature of the Sequence File is that it has been
subjected to the process of electropolishing, which is very signicant because
of the benets gained from such a treatment.
Electropolishing removes many of the imperfections in the NiTi that can
have catastrophic consequences. For example, electropolishing is very
eective at inhibiting crack propagation in NiTi blanks. These cracks have
been shown repeatedly to be a major cause of instrument separation. In
addition, the creation of a superior nish will keep the edge of the NiTi
instrument sharper, cleaner, and more durable. The result of these benets is
a rotary le with more cutting eciency, less lateral resistance, and increased
resistance to wear. Electropolishing can extend the life of a rotary le, but
the Sequence File has been designed to be part of a single-use system. Simply
put, electropolishing makes any rotary le safer and better (Fig. 3).
It also must be noted that at the current time, the Real World Endo
Sequence File is the only constant-taper rotary le system that is subjected
to an enhancement procedure such as electropolishing. The authors believe
that this is a signicant advance in the manufacturing of constant-taper les.
Quality of manufacturing
It is not sucient to say that just because something is Swiss-made, it
means that it is excellent; however, there is a certain connotation to Swissmade and the authors believe that the proof is in the pudding. Real World
Endo is committed to the concept of Precision-Based Endodontics, and
this precision is a function of the quality of manufacturing.
On thorough inspection of a Sequence File, by rotating it slowly and
checking the consistency of rotation, one should see a shadow consistently
climbing up the helical angles from the tip to the handle. After inspecting
the edges, one can conrm the sharpness: when the le is pulled across
the ngernail (cuticle to tip), it will bite and engage. The sharp edges are
a function of its manufacturing process.
On inspection, one can also conrm the exibility of the Sequence File and,
more important, the shape memory of its NiTi blank. The shape memory is
superb. It is next to impossible to separate the handle from the shank.
169
Fig. 3. (A) Pretreatment view. (B) After traditional polishing. (C) After electropolishing.
170
It is with supreme condence that the authors can say that the Sequence
File has been manufactured to the highest possible standards. The authors
challenge any other manufacturer to meet these simple yet rigorous
standards.
Taper
The Real World Endo Sequence File is available in both 0.04 and 0.06
tapers. Most important, these are fully tapered les, which means that the
working shank is 16 mm, not a reduced 9 or 10 mm. A full working shank is
signicant because it will allow the practitioner to machine a preparation
in a precise, crown down fashion. Not only will this technique contribute to
painless endodontics but it also will make the primary cone t an easy
match. Obturation becomes much easier when you have a fully tapered
machined preparation.
Tip design
It is a goal of Real World Endo to have clinicians perform not only
ecient endodontics but also safe endodontic procedures. Consequently, the
Sequence File uses a precision tip. A precision tip, by denition, is
a nocuutting tip that becomes active right at D-1. The result is safety
(nonperforating) combined with eciency. This is exactly what we want to
have in a tip design (see Fig. 1) It is truly amazing how such an eective
cutting le can remain centered in the canal. This ability to remain centered
is the result of a precision tip combined with ACPs of the blank design. This
concept is a new and revolutionary one.
Cutting eciency
The Sequence File has superb cutting eciency. The only other le that
the authors have seen with a similar eciency is the ProTaper. Although the
ProTaper also employs a triangular bank design, it is somewhat modied.
What gives the Sequence File extra cutting eciency is the electropolishing
that results in its characteristically sharp edges. Furthermore, the ACP
design allows the portion of the instrument that is engaged to really work in
an ecient manner because the full shank is not totally engaged and there is
no encumbrance of radial lands.
Experience has shown that the Sequence File cuts so eectively that the
operator must be aware to wipe clean or change the le after three pecks (or
engagements) of the le. After a brief period of time (3 to 5 seconds), the
operator can actually see the utes (which are a reamer design) begin to
accumulate debris. This accumulation is a result of the les superb cutting
eciency. Consequently, the operator and the assistant need to be
conscientious about cleaning the le. The le should be in the canal only
for 3 to 5 seconds before cleaning.
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Another wonderful aspect of its cutting eciency is how well and how
fast the Sequence File can enlarge a canal preparation. For example, many
times a clinician may be able to reach the working length of a mesial buccal
canal (in a lower molar) with only a size 15 le. The following attempt to
enlarge this preparation to a size 20, 25, or 30 may be extremely dicult and
frustrating. It is astonishing how the Sequence File is quickly able to enlarge
the preparation to a size 25 or 30. Best of all, there is no transportation. This
ability of the Sequence File to withstand transportation is a function of its
ACPs, precision tip, and excellent exibility. Clinicians will immediately
notice the dierence when comparing the ability of the Sequence File with
any other fully tapered landed le to withstand transportation.
Resistance
The Sequence File, without question, generates the least lateral resistance
of any constant-tapered rotary le system, which is a result of its triangular
reamer-like design, extremely sharp edges, electropolishing, and lack of
radial lands. The manufacturer has combined all these features into a single
le, with the result being the lowest torque requirements of any constanttapered rotary le system.
Flexibility
As previously mentioned, the exibility of this le is outstanding. The
ability to create a le that stays centered, without the need for radial lands,
results in greater exibility of the le. Flexibility becomes a tremendous asset
in rotary endodontics as the clinician begins to tackle more dicult cases. In
fact, endodontists will always continue to be challenged by more dicult
cases. Consequently, the need to have a exible le becomes paramount to
perform quality endodontics.
The key point to remember concerning exibility is this: exibility is not
the same among the various rotary les and it most certainly should not be
taken for granted.
Pitch/helical angles
The Sequence File has both variable pitch and variable helical angles.
The result is less of a tendency to pull down into the canal, which is further
enhanced by its blank design (ACPs) and the lack of radial lands. The net
result of these features is greater control. Control over the le means control
over the procedure.
To consistently achieve Precision-Based Endodontics, manufacturing
excellence must be combined with clinical control. Although the Sequence
File is very ecient at cutting, it nonetheless has excellent debris removal as
a result of its variable helical angles.
172
Speed
The Sequence File has been shown, through test cases (both clinically and
bench top), to work best in a range of 450 to 600 rpm. The ideal speed may
vary a little according to clinician preference and engine. Every engine the
authors have worked with seems to have an optimal rpm for specic les.
This concept is analogous to marine engines in which a boat will plane and
perform smoothly at a certain rpm, but at other rpm, the boat will
experience some noise and vibration.
The authors personal preference is 600 rpm, which they have found to
work well in multiple engines. The authors particularly like the way this le
performs in a portable engine (Fig. 4).
Historically, portable engines have been challenged when running fully
tapered 0.06 rotary les because the radial lands on the previous generations
of rotary les produced excessive lateral resistance. Due to the ACP design
(no lands) and its lack of torque requirements, however, the Sequence File
runs superbly in a portable handpiece.
It also is a goal of Real World Endo to remove as many rheostats as
possible from the treatment room. The day is coming when clinicians will be
able to perform rheostat-free endodontics.
It must also be pointed out that the Sequence File has a tendency to click
in the canal. In the past, this clicking might have been cause for alarm;
however, it is not unusual for a triangular-shaped blank. If the clicking
becomes a clacking (or clearly noisy), however, then it means that you are
pushing too hard on the le. The clacking will disappear when the le is not
pushed as hard. The rpm should not be reduced because the clacking is
a result of excessive force, not rpm.
173
In the authors experience, rotary les that are run at too low a speed
(150175 rpm) result in increased breakage. This breakage takes place
because the le is going so slowly that there is a tendency for the clinician to
force the le. A le should never be forced. By running the handpiece at the
proper rpm (450600 rpm), the clinician can let the le do the work.
Now that the design features of the Sequence File have been discussed,
the following section addresses clinical technique.
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175
simply go back into the canal with a 20/0.06 Sequence File, which will
readily go to the working length. This procedure is easily accomplished
because the Sequence le is extremely ecient at enlarging a previously
created glide path.
The aforementioned technique works very well for the overwhelming
majority of cases; however, in extremely dicult, narrow canals, the authors
slightly modify the technique to reduce stress on the le.
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Fig. 6. Case 1. (A) Failed 0.02 taper hand ling case. (B) Successful retreatment with 0.06 taper
rotary les.
Summary
In review, the entire Real Word Endo Sequence File technique is based
on the concept of using an Expeditor le and then choosing the size of the
canal. The canal size is either small, medium, or large, and each corresponding package contains the four les necessary to properly shape the
177
Fig. 7. Case 2. (A) Preoperative radiograph of mandibular molar. (B) Postoperative radiograph
showing machined preparations. (Courtesy of Dr. Ali Nasseh.)
canal. Generally, the canal preparation will require only three les, but
a fourth le has been included for challenging cases (Figs. 610).
Although the Sequence File is unique in being both procedural and
precision based, it is also dierent in terms of its handling ability. It is
a rotary le, and like all rotary les, it should not be forced. As previously
mentioned, if this le is muscled, then a clacking of the instrument is
heard. This is a heads-up to reduce the pressure on the le. When the
proper technique associated with this le is learned, however, the clinician
178
Fig. 8. Case 3. (A) Midroot area on mandibular premolar. (B) Working lm displays
precision of preparation. (C) Postoperative radiograph. (Courtesy of Dr. Ali Nasseh.)
179
Fig. 8 (continued )
The Sequence File is not used like previous rotary les that had
radial lands; that is, the le is not taken to resistance and back, to resistance and back, and so forth. The Sequence File also is not used with short
staccato-like pecks. Instead, it is used in a single 1-2-3 motion. The le
is taken to engagement (1) and back, to engagement (2) and back, and
nally to a third engagement (3), and out of the canal. The clinician
will very quickly learn this rhythm. It is the rhythm of precision
endodontics.
Always clean the le after three engagements. It is recommended that the
clinician perform two series of three engagements each before going to the
next le. Each series of engagements should take approximately no more
than 3 to 5 seconds.
What is meant by engagement? When performing this technique, the
clinician can actually feel the Sequence File engage the walls of the canal and
begin to work. As soon as the clinician feels the le engage, the le should
be slightly retracted (12 mm) and then reinserted for another engagement.
By using this technique, the clinician is instrumenting the canal millimeter
by millimeter.
The portable handpiece allows clinicians to work strictly with their
ngers (thumb to middle nger). So, instead of controlling the le from the
wrist area (as is done with thicker, landed les), we now have, for the rst
time, a rotary le that is controlled by nger tip pressure. This adds greatly
to the overall control of the procedure and will more easily allow the
clinician to achieve Precision Based Endodontics.
180
Fig. 9. Case 4. (A) Preoperative radiograph of maxillary bicuspid. (B) Completed case showing
conservative aspect of machined preparations. (Courtesy of Dr. Emanuel Alvaro.)
The following list reviews the basic Real World Endo Sequence File
technique:
1.
2.
3.
4.
5.
6.
The following list reviews the basic Real World Endo Sequence File
technique (straight crown down):
1. Conrm coronal patency with a size 10 stainless steel hand le. The le
only needs to go to approximately one half of the projected working
length. If a canal is patent in the coronal third, then it usually will be
181
Fig. 10. Case 5. (A) Preoperative radiograph of molar. (B,C) Working lm displaying precision
of Sequence File cone t. (Courtesy of Dr. Ali Nasseh.)
open to the apex. Too many dentists make the mistake of trying to force
a hand le to length before coronal aring.
2. Determine canal size based on the preoperative radiograph, the t of the
size 10 stainless steel hand le, and the depth of penetration of the
Expeditor. Canal size is generally small, medium, or large.
3. Begin crown down with a le from the appropriate le-size package.
4. Establish working length with a size10 hand le and an apex locator
after using the second rotary le from the package. Determine working
length after the second rotary le to take advantage of the crown down.
182
Fig. 10 (continued )
184
Fig. 1. File cross-sections. (A) K-le, RaCe. (B) ProFile, GT, LightSpeed. (C) Hero 642. (D)
K3. (E) ProTaper, Flexmaster. (F ) ProTaper F3.
instruments cut more eectively and more aggressively and have a tendency
to straighten the canal curvature. In addition, the more positive the rake
angle of the blade, the more aggressive the cutting action of the instrument.
Passive instruments perform a scraping or burnishing rather than a real
cutting action, remove dentin slower, and have less of a tendency for canal
straightening.
Key features of all instruments introduced here are three blades and
a passive, noncutting tip. ProFile (Dentsply Tulsa Dental, Tulsa,
Oklahoma), GT (Dentsply Tulsa Dental), LightSpeed (LightSpeed Technology Inc., San Antonio, Texas), and others belong to the family of passive
185
Size (mm)
Color code
2
3
4
5
6
7
8
9
10
0.129
0.167
0.216
0.279
0.360
0.465
0.600
0.775
1.000
Silver
Gold
Red
Blue
Green
Brown
Silver
Orange
Red
186
187
ProTaper instruments are unique among all NiTi rotary instruments in that
they have dierent tapers along a single instrument (multitapered instruments). The set consists of six instruments: three shaping instruments (SX,
S1, S2) and three nishing instruments (F1, F2, F3). The main dierence
between the S and F instruments is that S instruments have an increasing
taper from tip to top, whereas the F instruments have a decreasing taper
from tip to top. Shapers mainly cut in the middle third of the root canal with
their tips, following the glide path so as to create an access for the nishers
that will cut in the apical third of the root canal. A set of ProTaper
instruments used sequentially will only cut along a short distance in the
canal, touching little canal wall surface. This eect will reduce the torque
load and increase the cutting eciency of each individual instrument. The
convex utes of the largest instrument (F3) have been cut out to a more
convex form, reducing the stiness and increasing the exibility of this
strong instrument (Fig. 1F). The tip size of F3 is 30; the taper at 3 mm from
the tip, however, is 9%. At 2 mm from the tip, the diameter is size 48; at
3 mm, it is size 57.
188
To understand the concept of a hybrid sequence of biomechanical instrumentation, three dierent approaches to enlarging a root canal (crown down,
step back, and apical widening) are summarized in the following sections.
Crown down
The crown down idea is to step apically by using a series of les while
decreasing instrument size or instrument taper. The next smaller le will
perform its cutting action deeper in the canal, leaving the engaging surface
of each instrument minimal and, therefore, decreasing the torque load of
each instrument. Repeating the use of such a series of les will also result in
either gaining deeper access into the canal or enlarging the canal further by
each sequence. Fig. 2 shows the decreasing taper approach with a classical
GT le set. The tip size of each instrument is ISO 20, with tapers of 0.12
(blue), 0.10 (red), 0.08 (yellow), and 0.06 (silver). The arrows in Fig. 2
indicate the areas where the individual instruments engage the dentinal
walls. Crown down minimizes coronal interference, eases instrument
Fig. 2. Crown down approach with decreasing taper. Arrows indicate corresponding cutting
area.
189
190
during instrumentation will reduce the contact area of the instrument with
the root canal wall and, therefore, reduce the torque load and increase the
cutting eciency and safety.
Working length
The next step is the working length determination. There are ve methods
available (dierently angulated radiographs, electronic apex locator, tactile
sense, paper point control, patient sensation); a combination of at least the
rst two should be used on a regular basis.
191
Fig. 3. Straight line access in an upper molar. (A) Before straight line access. (B) After straight
line access. (C) After completion of instrumentation; buccal canals.
192
Fig. 4. Straight line access on radiograph. Dotted lines and arrows indicate areas of dentinal
overhang to be removed.
instrument binding at the working length. From this size, the apex should be
enlarged at least three to four ISO sizes bigger; however, averages cannot
apply in every case. A clinical judgment needs to be made to dene the MAF
size. All information available about the anatomy of the canal system and
the technical diculty of the case should be taken into consideration. The
ideal apical preparation would result in a consistently round form because
this allows for better cleaning of the entire canal wall and better apical seal
[18,19]. In many cases such as ribbon-shaped canals, this goal cannot be
achieved; however, clinicians should try to reach as close as possible to this
goal whenever possible, which often means enlarging the canal wider than
previously thought.
Glide path
Before using any NiTi rotary instruments, a glide path for these
instruments up to ISO size 20 with stainless steel K hand les (0.02 taper)
needs to be created so that the fragile tips of small-sized NiTi rotary
instruments can follow the path without exploring the canal or cutting. Even
light pressure or a small amount of torque would otherwise fracture these
instrument tips.
193
Body shaping
The next step is a fast and eective removal of the coronal and middle
canal third. The classic GT le set (see Fig. 2) has been successfully used for
this purpose in decreasing taper order in a crown down manner. This
sequence can be repeated several times if necessary until working length is
reached. Often, the original apical canal diameter is larger than size 20, so
the resulting canal form is ared, with an apical diameter of at least size 20.
Active instruments such as ProTaper can perform this step even more
eectively. The ProTaper shaping instruments SX, S1, S2 are ideal for this
purpose. They rst shape the canal to a ared form with more taper
coronally than apically, similar to the shape of the Eiel Tower in Paris,
France. Then, the taper is increased gradually deeper down into the canal.
This technique is also considered a crown down approach: the taper is
moved crown down, leaving a canal form that allows ideal access for the
apical preparation.
Apical preparation
Apical preparation consists of four steps (apical pre-enlargement, apical
enlargement, apical LightSpeed preparation, and apical nishing) that are
described in the following sections. All four steps may not be necessary in
each individual case, because dierent canals require dierent approaches.
Apical pre-enlargement
The idea of apical pre-enlargement is to cut quickly and eectively the
apical canal third to a size to which the canal at working length can quickly
and safely be enlarged. In easy cases, this can be done with active instruments that cut aggressively. ProTaper nishing instruments F1 to F3,
for example, will leave an ideal preparation form, provided that F3 reached
the working length. This instrument sequence will move the canal taper even
further apically (crown down). ProTaper plays a major role in this hybrid
concept: a full sequence of these instruments can subsequently perform both
body shaping and apical pre-enlargement with ease.
Only the apical 2 to 3 mm need to be further enlarged. The more dicult
the case (the more severe the curvature or the smaller its radius), the more
the clinician should decide to use passive instruments. In very dicult cases,
NiTi rotary instruments also can be used by hand.
194
Table 2
Diameter comparison between the multi-tapered ProTaper F3 instrument and 3 consistently
nickeltitanium instruments with tapers of 2%, 4%, and 6% in size 35
Diameter of ProTaper F3
(9%)
(7%)
(6%)
(4%)
(2%)
0
1
2
3
4
5
0.30
0.39
0.48
0.57
0.64
0.71
0.35
0.37
0.39
0.41
0.43
0.46
0.35
0.36
0.38
0.39
0.41
0.42
0.35
0.36
0.36
0.37
0.38
0.39
Apical enlargement
After pre-enlarging the apex safely, it often needs to be enlarged more,
based on the decision of which size MAF should be used for the individual
canal. Apical enlargement can be performed with active or passive tapered
instruments, depending on the diculty of the canal curvature.
Tables 2 through 5 show diameter comparisons at dierent levels from
the tip of the multi-tapered ProTaper F3 instrument and other NiTi rotary
instruments with consistent tapers of 0.06 (6%), 0.04 (4%), and 0.02 (2%).
Table 2 compares an instrument with a tip size of 35, Table 3 with size 40,
Table 4 with size 45, and Table 5 with size 50. Areas in which the
consistently tapered instruments are larger than the ProTaper F3 instrument
are highlighted in gray. Provided that a ProTaper F3 instrument has
reached the working length, it becomes obvious that a size 35 instrument
(regardless of the taper) used after a ProTaper F3 instrument to the same
length in the canal only cuts at the very tip (up to less than 1 mm from the
tip) because at 1 mm from the tip, the size prepared by ProTaper F3 is
already size 39 (see Table 2). Table 5 shows that a size 50 instrument with
a 0.06 taper will cut along the 4 mm from the tip, whereas a size 50
instrument with a 0.02 or 0.04 taper will cut only at the apical 3 mm. The
Table 3
Diameter comparison between the multi-tapered ProTaper F3 instrument and 3 consistently
tapered nickeltitanium instruments with tapers of 2%, 4%, and 6% in size 40
Diameter of ProTaper F3
(9%)
(7%)
(6%)
(4%)
(2%)
0
1
2
3
4
5
0.30
0.39
0.48
0.57
0.64
0.71
0.40
0.42
0.45
0.47
0.50
0.52
0.40
0.42
0.43
0.45
0.46
0.48
0.40
0.41
0.42
0.42
0.43
0.44
195
Table 4
Diameter comparison between the multi-tapered ProTaper F3 instrument and 3 consistently
tapered nickeltitanium instruments with tapers of 2%, 4%, and 6% in size 45
Diameter of ProTaper F3
(9%)
(7%)
(6%)
(4%)
(2%)
0
1
2
3
4
5
0.30
0.39
0.48
0.57
0.64
0.71
0.45
0.48
0.50
0.53
0.56
0.59
0.45
0.47
0.49
0.50
0.52
0.54
0.45
0.46
0.47
0.48
0.49
0.50
idea of this comparison becomes clear: after having reached the working
length with a ProTaper F3 instrument, it is not dicult to enlarge the apex
even wider because other NiTi rotary instruments like FlexMaster or other
active or passive tapered instruments in sizes such as 40 with a 0.06 or 0.04
taper and even size 50 with a 0.02 taper can be used subsequently with
minimal coronal interference, minimal cutting surface, and therefore,
minimal torque load.
Provided in a clinical case that the desired MAF size is 45 and a 0.06
taper should be achieved, according to Table 4, only the apical 3 mm need to
be enlarged. To minimize the torque each instrument has to carry, a size/
taper sequence in the following order can be used: 35/0.04, 35/0.06, 40/0.04,
40/0.06, 45/0.04, and 45/0.06. If all instruments are used to working length,
then this corresponds to the apical widening concept. Accumulation of
dentinal shavings at the apex is almost completely avoided. The number of
instruments for this step of instrumentation seems large, but each instrument cuts only minimally and its cutting action is accomplished quickly
after only one to three rotations. This process can easily be done using the
instruments by hand, and it is safer and faster than changing the les in
a motorized handpiece.
Table 5
Diameter comparison between the multi-tapered ProTaper F3 instrument and 3 consistently
tapered nickeltitanium instruments with tapers of 2%, 4%, and 6% in size 50
Diameter of ProTaper F3
(9%)
(7%)
(6%)
(4%)
(2%)
0
1
2
3
4
5
0.30
0.39
0.48
0.57
0.64
0.71
0.50
0.53
0.56
0.59
0.62
0.65
0.50
0.52
0.54
0.56
0.58
0.60
0.50
0.51
0.52
0.53
0.54
0.55
196
The more severe the curvature, the smaller the taper of the apical
preparation should be and the more the clinician should decide to use
passive instruments. At several millimeters from the working length, the
dierence in size between the existing ProTaper preparation and the size of
the instrument used for the apical enlargement becomes so big that this
instrument can slightly straighten in the canal curvature and therefore does
not need to be bent so hard to follow the curvature. In some cases, the
severity of the curvature may not have allowed the use of the same
instrument around the particular curvature without previous apical preenlargement as described earlier.
Apical LightSpeed preparation
This step is necessary when the desired MAF size is bigger than a size that
can be prepared with tapered instruments in a curved canal [21].
The apex will be enlarged to the desired size starting with a LightSpeed
instrument that is one LightSpeed size larger than the last instrument that
previously reached the working length. The instruments are all used to
working length in increasing size order, and no instrument should be left
out. Because the resulting apical canal form is cylindric, a step back is
needed to create a taper in the apical part of the canal. Step back
increments of 0.5 mm for each LightSpeed size will result in a 0.05 taper;
1-mm increments will give a 0.025 taper. The form of this pseudo-taper,
however, leaves steps in the canal wall. The irrigation needle or the gutta
percha cones might not be able to smoothly bypass these steps on the outer
wall of the canal curvature.
197
Fig. 6. (AC) Sample case 1. See text for detail of the case.
Apical nishing
Apical nishing can be performed using the LightSpeed MAF size instrument or another passive instrument in a 0.02 or 0.04 taper and a size that
follows to working length easily. The instrument will be forwarded to
working length in a clockwise rotating or a watch-winding motion one or
two times by hand. This smoothes the steps in the outer wall of the
curvature and merges the step back taper into the more coronally located
taper.
Hybrid sequences overview
The whole idea of the hybrid concept can be condensed to the overview
shown in Fig. 5. The left side represents easy cases. Toward the right side,
the cases become more dicult. The body shaping and apical preenlargement, in most cases, can be managed with ProTaper instruments,
and in extremely dicult cases, with passive instruments. The apical
enlargement according to the diculty of the case can be performed with
active or passive instruments, and if the MAF size demands, then it can be
performed with LightSpeed. The apical nish after LightSpeed step back
can follow by hand with the LightSpeed MAF size or another passive
instrument that can follow to working length without much eort. As new
instruments are developed, they can be integrated into this hybrid concept.
198
Fig. 7. (AC) Sample case 2. See text for detail of the case.
Sample cases
Figs. 6 through 10 show several clinical cases in ascending order of
diculty. The protocols of instrumentation used for each case are described
below.
In case 1 (Fig. 6), having a mild curvature, straight line and radicular
access were performed with GG burs in descending order from 4 to 1.
Instrumentation to ProTaper F3 completed body shaping and apical preenlargement. Apical enlargement was done with Flexmaster instruments of
size/taper 35/0.04, 35/0.06, 40/0.04, and 40/0.06. Taper lock was avoided.
Active instruments were used exclusively according to the low-grade
diculty of the case.
Case 2 (Fig. 7) also had a mild curvature. Straight line and radicular
access were performed with GG burs in descending order from 4 to 1. Body
shaping and apical pre-enlargement were managed with ProTaper to F3.
Apical enlargement was performed with passive ProFile instruments. For
the distal canals, ProFile instruments of size/taper 35/0.04, 35/0.06, 40/0.04,
40/0.06, 45/0.04, 50/0.04, and 55/0.04 were used. The isthmus has been
completely opened with ultrasonic instruments and Hedstrom hand instruments. The mesial canals were completed with ProFile instruments of size/
taper 35/0.04, 35/0.06, 40/0.04, and 45/0.04.
Case 3 (Fig. 8) was moderately curved. Straight line and radicular access
were performed with GG burs in the following order: 1 to 3, 4 to 1.
199
Fig. 8. (AD) Sample case 3. See text for detail of the case.
200
Fig. 9. (AC) Sample case 4. See text for detail of the case.
201
Fig. 10. (A, B) Sample case 5. See text for detail of the case.
202
References
[1] Knowles KL, Ibarrola JL, Christiansen RK. Assessing apical deformation and transportation following the use of LightSpeed root canal instruments. Int Endod J 1996;29:
1137.
[2] Thomson SA, Dummer PMH. Shaping ability of LightSpeed rotary nickel-titanium
instruments in simulated root canals. Part 2. J Endod 1997;23:7427.
[3] Vulcain J, Calas P. The three wave concept of HERO 642. Endod Pract 1999;2:2031.
[4] Gabel WP, Hoen M, Steiman HR, Pink FE, Dietz R. Eect of rotational speed on nickeltitanium le distortion. J Endod 1999;25:7524.
[5] Dietz DB, Di Fiore PM, Bahcall JK, Lautenschlager EP. Eect of rotational speed on the
breakage of nickel-titanium rotary les. J Endod 2000;26:6871.
[6] Baumann M, Roth A. Eect of experience on quality of canal preparation with nickeltitanium les. Oral Surg Oral Med Oral Pathol 1999;88:7148.
[7] Blum JY, Machtou P, Micallef JP. Location of contact areas on rotary ProFile instruments
in relationship to the forces developed during mechanical preparation of extracted teeth.
Int Endod J 1999;32:10814.
[8] Schilder H. Cleaning and shaping the root canal. Dent Clin N Am 1974;18:26996.
[9] Moodnik RM, Dorn SO, Feldman MJ, Levey M, Borden BG. Ecacy of biomechanical
instrumentation: a scanning electron microscopic study. J Endod 1976;2:2616.
[10] Weine FS. Intracanal treatment procedures, basic and advanced topics. 5th edition. St.
Louis (MO): C.V. Mosby; 1996.
[11] Grossman LI. Endodontic practice. 8th edition. Philadelphia: Lea & Febinger Co.; 1974.
[12] Levin JA, Liu DT, Jou YT. The accuracy of two clinical techniques to determine the size of
the apical foramen [abstract]. J Endod 1999;25:294.
[13] Wu MK, Barkis D, Roris A, Wesselink PR. Does the rst le to bind correspond to the
diameter of the canal in the apical region? Int Endod J 2002;35:2649.
[14] Kuttler Y. Microscopic investigation or root apexes. J Am Dent Assoc 1955;50:54452.
[15] Kerekes K, Tronstad L. Morphometric observations on the root canals of human anterior
teeth. J Endod 1977;3:249.
[16] Kerekes K, Tronstad L. Morphometric observations on the root canals of human
premolars. J Endod 1977;3:749.
[17] Kerekes K, Tronstad L. Morphometric observations on the root canals of human molars.
J Endod 1977;3:1148.
[18] Luks S. Guttapercha versus silver points in the practice of endodontics. N Y State Dent
J 1965;31:34150.
[19] Hwang HK, Jou YT, Kim S. Sealing ability of isthmuses by dierent obturation techniques
[abstract]. J Endod 1998;24:283.
[20] Roane JB, Sabala CL, Duncanson MG. The balanced force concept for instrumentation in
curved canals. J Endod 1985;11:20311.
[21] Hulsmann M. Wurzelkanalaufbereitung mit Nickel-Titan-Instrumenten. Kombinierte
Technik. 1st edition. Berlin: Quintessenz Verlags-GmbH; 2002.
204
of the working length. The nger is then removed from the coil and the
System B tip is allowed to cool down. Because the tips are hollow, they heat
up almost instantaneously to the set temperature. After allowing the tip to
cool for 10 seconds while still in the canal, the coil is engaged for a split
second while pushing apically, and then the tip is withdrawn from the canal
with the now-severed gutta percha wrapped around the tip. There will be
a learning period when a clinician new to the technique pulls out the entire
gutta percha cone from the canal instead of leaving behind that apical plug.
When this happens, it means there was not adequate tug back of the master
cone and a new cone will need to be retted [3]. Nonstandardized medium
gutta percha cones and a gutta gauge can be used to customize those master
205
Fig. 3. The Obtura II unit comes complete with instructional video and plastic practice blocks.
Fig. 4. The medium System B tip compares closely to a medium gutta percha cone and a 0.06
taper rotary nickeltitanium le.
206
cones (Fig. 5). The medium gutta percha cones most closely resemble the
0.06 taper created in the canals, but 0.04 and 0.06 taper standardized gutta
percha can now be purchased.
Because of the heat transfer process of the System B, there is now
a softened apical plug of gutta percha in the canal. The next step is to
207
Fig. 6. Apical plug of gutta percha remains in canal and can now be packed down.
condense this plug of gutta percha, achieving a better seal apically (Fig. 6).
This is where the new S-Kondensers from Obtura/Spartan come in handy.
The S-Kondensers have improved on several problems that existed with
other condensers. They are ISO standard colors, so that the black is size 40nickel titanium on one end and size 80- stainless steel on the other end. The
yellow S-Kondenser is 50-nickel titanium and 100- stainless steel, and the
blue S-Kondenser is 60-nickel titanium and 120- stainless steel. The nickel
titanium end is marked at 5 mm intervals (Fig. 7), to better gauge when you
have reached the desired apical distance, and has a .02 taper which gives
you excellent compressive strength without compromising exibility. The
handles are made of an anodized aluminum, which is easy to clean and
maintains its color throughout autoclaving. The handles are notched to
provide a nger rest, positioned so that you can grip the S-Kondenser
comfortably and apply rm pressure during condensation (Fig. 8).
After down packing the apical plug of gutta percha we are ready for the
Obtura II to back ll each canal (Fig. 9). The Obtura II has helped to
improve the density of lls as well as increasing eciency. The obturation
phase of treatment has now become the easy part of a root canal [4]. The
208
209
210
211
percha would extrude out the sides. You must place the Obtura II tip in the
canal and make contact with the apical plug of gutta percha before back
lling. Once the tip is in contact with the now cooled apical gutta percha
plug, let it remain there for three seconds, re-heating that apical plug. This
will prevent voids from occurring between the apical gutta percha and the
remainder of the lling (Fig. 12). If you hear a crackling noise while injecting
the gutta percha, it is an air pocket, and will not aect the ll, as long as you
continue to press the trigger, lling the canal. You may back ll in one
motion, not segmentally, and after completing the back lling of each canal,
backpack with the stainless steel end of the S-Kondenser. The root canal is
now complete.
Most so-called problems with obturation are actually problems with
ones instrumentation. The obturation is in essence an impression of what
the canal looks like after it has been instrumented. If one is not happy with
the appearance of the nal x-ray, you are actually criticizing the
instrumentation/aring of the canals. If the master gutta percha cone does
not seat all the way to the desired working length, you must go back with
a le to make sure there is no debris in the canal and that the aring is
adequate. If the master cone goes beyond the apex (Fig. 13), you must
212
Fig. 14. (A) Preoperative radiograph of retreatment of maxillary rst molar. (Courtesy Kevin
Edwards, DDS, Portland, Oregon) (B) Postoperative radiograph.
213
Fig. 15. (A) Preoperative radiograph of mandibular bicuspid with trifurcation of canals.
(Courtesy Kevin Edwards, DDS, Portland, Oregon) (B) Postoperative radiograph.
Fig. 17. Maxillary molar with long but gentle curvature of MB root.
Fig. 18. (A,B) Mandibular molars with lateral canals lled in apical third of distal root.
215
inability to properly seat two master cones side by side in the palatal
canal.
Another case where the warm vertical technique was necessary was
a mandibular bicuspid with a trifurcation of its canal (Fig. 15). Three separate
master cones were used, with each cone being burned out apically to the
trifurcation, allowing room for the next master cone to be seated. After the
three master cones were placed and the System B used to leave three apical
plugs of gutta percha, the whole system was back lled with the Obtura II.
A few more cases such as this maxillary molar with four canals (Fig. 16)
and another maxillary molar with a long gentle curve (Fig. 17), depict the
results obtainable with the above described obturation technique. These two
mandibular molars (Fig. 18) have small lateral canals in the apical third, and
with the warm vertical technique using a thermoplasticized (semi-solid) form
of gutta percha, you will see a higher incidence of lling such lateral canals.
There are many approaches to solving a problem. Similarly, in endodontics, there are several ways to instrument and to obturate the root canals.
Practitioners often develop their own hybrid technique, using ideas
from several colleagues. The purpose of this chapter was to share a technique
of obturation, with the hope that others may incorporate some aspects into
their own style.
References
[1] Guess G, Edwards K Yang ML, Iqbal M, Kim S. Analysis of continuous S-Kondensers
wave obturaton using a single-cone and hybrid technique. J Endodon 2003;29:50912.
[2] Schilder H. Filling root canals in three dimensions. Dent Clin N Am 1967;1:72344.
[3] Weller RN, Kimbrough WF, Anderson RW. A comparison of thermoplastic obturation
techniques: adaptation to the canal walls. J Endodon 1997;23:7036.
[4] Buchanan LS. Continuous wave of condensation technique. Endodon Pract 1998;1:718.
218
Fig. 2. MicroSeal nger spreaders (size/taper): 20/0.02 (top), 25/0.02 (middle), 25/0.04 (bottom)
(SybronEndo).
Fig. 3. MicroSeal engine spreaders (size/taper): 25/0.04 (top), 25/0.02 (middle), 20/0.02 (bottom)
(SybronEndo).
219
Fig. 5. MicroSeal condenser size 25, 0.04 taper. Measurement of the angle between the blades
and the axis of the instrument (SybronEndo).
220
Fig. 6. Vertical and lateral forces generated by the MicroSeal condenser (SybronEndo).
Fig. 7. MicroSeal gutta percha cones (size/taper): 25/0.04 (far right), 25/0.02 (middle right), 30/
0.02 (middle left), 35/0.02 (far left) (SybronEndo).
221
222
Fig. 9. Radiograph conrming the length of the master cone (MicroSeal, SybronEndo).
MicroSeal condenser
Particularly interesting is the MicroSeal condenser (Fig. 4). This
instrument is made of NiTi, has a reverse helix design, and is available
in 0.02 taper in sizes 25 to 60 and in 0.04 taper in size 25. The condenser is
223
Fig. 10. MicroSeal spreader reaches the proper length alongside of the master cone
(SybronEndo).
Fig. 11. MicroSeal condenser coated with warm gutta percha from the cartridge (SybronEndo).
224
Fig. 12. MicroSeal condenser carries warm gutta percha into the canal (SybronEndo).
into all the spaces within the root canal. Because it is made of NiTi, it is
highly exible and can reach the apical 2 to 3 mm in most cases.
On careful inspection of the angle between the reverse blades of the
condenser and the axis of the instrument, a decrease in amplitude from
Fig. 13. Tooth No. 19. Apical hook in the distal root.
225
Fig. 14. (A) Preoperative radiograph for tooth No. 23 showing an apical bifurcation. The tooth
has been prosthetically prepared before the root canal. (B) Postoperative radiograph for tooth
No. 23. Note the small access cavity to preserve the prosthetic preparation and the management
of the apical bifurcation.
the handle to the tip can be noticed; that is, the angle between the blade and
the shaft is more open in the coronal part and gradually becomes more closed
in the apical part. The authors measurements, using Cad-Cam software,
provided an angle varying from 60 to 30 (Fig. 5). This assessment has a very
important clinical implication. In fact, the forces generated by the rotating
condenser are directed apically mostly in the coronal part of the instrument
and laterally at the tip level. This unique design is most likely thought to
prevent the possibility of extrusion of the gutta percha beyond the apical
constriction. Also, for these reasons, the condenser can be considered to act
as a plugger in the coronal part of the root canal and as a spreader in the
apical region, generating vertical and lateral forces selectively (Fig. 6).
226
Fig. 14 (continued )
227
breakage of the chemical links of the polymer. Conversely, cooling of the aphase gutta percha will produce b-phase gutta percha, and shrinkage occurs
during this process. Therefore, to compensate for the undesirable shrinkage
of the gutta percha for obturation methods using warm gutta percha, it has
been suggested to compact the material while it is cooling with the use of
a plugger [10].
228
Fig. 17. Use of accessory cones to create an apical stop for canals with oval foramen.
In the MicroSeal system, the cones are made of a-phase gutta percha at
room temperature. In this way, only minimal shrinkage takes place during
the cooling phase.
For the same reason, the gutta percha cartridges consist of ultralowfusing gutta percha. For infection control purposes, the gutta percha
cartridges are made for single-patient use only.
229
Fig. 18. Radiographic comparison of gutta percha cones size 30, 0.02 taper from the following
brands: Hygenic ( far left), Caulk Densply ISO color (middle left), Caulk Densply ISO noncolor
(middle right), and MicroSeal ( far right).
Fig. 19. Gutta percha cones tested in the preclinical study: Hygenic, Caulk Densply ISO color,
Caulk Densply ISO noncolor, and MicroSeal.
230
Fig. 20. Radiographic comparison of gutta percha cones size 30, 0.02 taper from Caulk
Densply ISO noncolor (left) and MicroSeal (right).
231
Fig. 21. Gutta percha cones from Caulk Densply ISO noncolor used in the preclinical test.
232
Fig. 22. Group 1, n 8. Radiographs in clinical (A) and proximal (B) view. Cross-sections at
the 1 mm (C), 5 mm (D), and 7 mm (E) levels.
After dipping the tip of the selected master cone into endodontic sealer, it
is introduced into the canal. The NiTi MicroSeal spreader is advanced to
within 1 to 2 mm from the working length and is rotated (Fig. 10). The
spreader is then removed from the canal; space has been created between the
master cone and the canal walls.
Next, the gutta percha cartridge is heated and the condenser is
introduced into the cartridge and gently removed to cover 5 to 6 mm of
the instrument with warm gutta percha (Fig. 11). The coated condenser
can now be introduced into the canal space created by the spreader
(Fig. 12).
233
Fig. 22 (continued )
234
Fig. 22 (continued )
235
Fig. 22 (continued )
Modications
The technique just described is the one recommended by the manufacturer. To improve some of the aspects of the technique, the following
suggestions are made by the author.
First, the use of the NiTi spreader is of great advantage, especially in the
case of curved canals, because it guaranties that the instrument reaches the
proper depth of 1 mm from the working length [9,11]. Alternately, in certain
clinical circumstances, as with a sharp apical hook (Fig. 13), the NiTi
spreader can be bent under pressure and may not transmit its compacting
force to the gutta percha cone. Also, there are root canal anatomies such as
apical bifurcations (Fig. 14) that require management by a prebent spreader,
236
Fig. 23. Group 2, n = 2. Radiographs in clinical (A) and proximal (B) view. Cross-sections at
the 1 mm (C), 4 mm (D), and 5 mm (E) levels.
and the NiTi spreader cannot be precurved [12]. Thus, the use of the
stainless steel spreader D11T can replace the NiTi nger spreader for the
apical compaction of the master cone where indicated (Fig. 15). In addition
to the apical compaction of the master cone, the author nds the use of
237
Fig. 23 (continued )
a more tapered spreader such as the D11 helpful to create more space,
specically in the coronal part of the canal (see Fig. 15). In this way, the
subsequent introduction of the condenser becomes easier and faster. For
this purpose, the D11 spreader is not supposed to reach the apical area
because its main action occurs at the orice level. It is very important that
the spreader D11 is not forced but is gently guided as far as it will go into the
root canal.
Second, the use of the master cone has the primary objective of creating
an apical stop. In this way, further use of the condenser coated with warm
gutta percha is prevented from pushing any lling material beyond the
apical constriction. Because there is a high variation in size and shape of the
apical anatomy, there are situations in which the master cone alone does not
238
Fig. 23 (continued )
completely seal the apex. In these situations, the apical foramen is oval in
shape (Fig. 16) or is ribbon shaped due to the conuence of two canals in the
same apical exit [13]. In such situations, in addition to the master cone, the
use of one or two accessory cones (generally 0.02 taper, size 25) may provide
a more secure apical stop against which the rotating condenser can be safely
pushed (Fig. 17). In fact, the use of one master cone in all cases could result
in some undesired overlling or underlling.
239
Fig. 23 (continued )
240
Fig. 23 (continued )
can achieve this result more predictably. Also, if one considers that the use
of one or two accessory cones in addition to the master cone is frequently
indicated, the selection of a 0.04 taper master cone would risk creating a bulk
of gutta percha at the orice level. This bulk would interfere with further
insertion of the condenser coated with warm gutta percha. Thus, the 0.02
taper master cone is the one more likely indicated in the majority of the
cases.
A fourth consideration is the use of the plugger at the end of each
compaction. It is true that the ultralow-ow gutta percha from the
MicroSeal system undergoes less shrinkage, but it is also true that after the
241
Fig. 24. Group 3, n = 1. Radiographs in clinical (A) and proximal (B) view. Cross-sections at
the 1 mm (C), 2 mm (D), 4 mm (E), 5 mm (F), 6 mm (G), and 6.5 mm (H) levels.
use of the condenser, an amorphous mass of gutta percha lls the canal.
To better adapt the melted lling material to the canal walls, the use of the
plugger is of great benet. The author believes that the obturation does not
end with the rotation of the condenser; the coronal compaction using
242
Fig. 24 (continued )
a plugger of proper size greatly increases the adaptation of the gutta percha
to the root canal system, prevents formation of voids, and ultimately
provides a more dense and homogeneous obturation.
Fifth, one of the main dierences between the MicroSeal gutta percha
cones and other brands of gutta percha cones is the radiopacity. The author
compared the radiopacity of the MicroSeal gutta percha cone with other
gutta percha cones on the market. The MicroSeal gutta percha cones appear
to be less radiopaque (Fig. 18), which may present a disadvantage because
the evaluation of the root canal lling is clinically done on the basis of its
radiographic density [4].
Fig. 24 (continued )
243
244
Fig. 24 (continued )
245
Fig. 25. Group 3, n 6. Radiographs in clinical (A) and proximal (B) view. Cross-sections at
the 1 mm (C), 3 mm (D), and 5 mm (E) levels.
Preclinical test
Sixteen straight single-rooted teeth were divided into four groups of 4
teeth each, with each group consisting of two narrow canals and two large
canals. All canals were instrumented using the same instrumentation
246
Fig. 25 (continued )
technique. After access was made, the prearing was accomplished using
GatesGlidden instruments in sizes 2, 3, and 4. The canals were prepared
using the Proles 0.06 taper. Canals were prepared up to size 35 or 45
depending on the initial apical size and were irrigated with sodium
hypochlorite and EDTA, alternating after each instrument. For the
Fig. 25 (continued )
247
248
Fig. 25 (continued )
obturations, the gutta percha cones were dipped in Grossman sealer in all
cases.
In group 1, the canals were obturated using one MicroSeal gutta
percha master cone, and no plugger was used after the condenser
rotation.
In group 2, the canals were obturated using one MicroSeal master cone
plus one or two accessory MicroSeal cones of 0.02 taper and size 25; the
plugger was used consistently after the condenser rotation.
In group 3, the canals were obturated using one master cone
manufactured by Caulk-Densply. No plugger was used after the condenser
rotation.
In group 4, the canals were obturated using one master cone plus
one or two accessory cones of 0.02 taper and size 25 manufactured by
Caulk-Densply, and the plugger was used consistently after the condenser
rotation.
After all the samples were prepared, they were sectioned at increments of
1 mm using a sectioning saw (Beuhler LTD, Lake Blu, Illinois) under cool
249
Fig. 26. Group 4, sample n = 6. Radiographs in clinical (A) and proximal (B) view. Crosssections at the 1 mm (C), 3 mm (D), 5 mm (E), and 7 mm (F) levels.
water. The sections were then stained with methylene blue and examined
under the operation microscope at 20 magnication.
Each sample was evaluated regarding the (1) adaptation of the gutta
percha to the canal walls, (2) presence of voids in the obturation, (3)
250
Fig. 26 (continued )
251
Fig. 26 (continued )
In group 2, regardless of the canal size, the adaptation of the gutta percha
to the canal walls was generally good. Voids were not observed in any of the
samples. Flowing of the gutta percha in lateral canals was observed in some
of the sections. The radiographic density was also evaluated as poor in this
group (Fig. 23).
In group 3, the adaptation of the gutta percha was considered good in
narrow canals and inconsistent in most of the large canals. The crosssections documented an unusual anastomosis in a lower anterior partially
lled with gutta percha (Fig. 24). The radiographic density was considered
satisfactory (Fig. 25).
In group 4, the adaptation of the lling material to the canal walls was
consistently good or very good, both in narrow and large canals. The lling
material was homogeneous and able to ow into the intricacies of the root
canal system and to adapt to dierent types of anatomy. The radiographic
appearance showed good contrast and was considered superior compared
with the other groups (Fig. 26).
252
Fig. 26 (continued )
253
Fig. 26 (continued )
Discussion
From this study, it appears that from the technical point of view,
there is no dierence between the use of the MicroSeal and the use of
254
Fig. 26 (continued )
Caulk-Densply gutta percha cones. They melt at the same rpm of the condenser after the instrument, coated with warm gutta percha, is introduced
into the canal. The cones, when melted, provide gutta percha that is homogeneously integrated with the MicroSeal gutta percha from the cartridge.
The only dierence appears to be the slightly better radiopacity of the
Caulk-Dentsply cones compared with the MicroSeal cones.
255
Fig. 27. MicroSeal condenser undergoing very high torsional stress before reaching the
breaking point (SybronEndo).
The cones from Hygenic and from Caulk Densply (ISO color) had very
dierent behavior compared with the MicroSeal and Caulk Densply ISO
noncolor cones in this preclinical study. In fact, the Hygenic cones and
the Caulk Densply ISO color cones seemed to be more elastic and
required a higher speed and more time for the condenser to start the
Fig. 28. Cross-section showing a fragment of MicroSeal condenser incorporated into the lling
material. (Courtesy of Dr. SH Baek, South Korea.)
256
Fig. 29. Tooth No. 32. (A) Preoperative radiograph. (B) Postoperative radiograph.
melting process. Also, it seemed that the gutta percha from these brands
(after melting) did not integrate homogeneously with the MicroSeal gutta
percha from the cartridge and, therefore, provided an unpredictable
obturation.
These observations are only clinical. Further research is needed to
investigate the molecular and physical properties of the MicroSeal gutta
percha cones compared with other brands.
The authors clinical observations suggest that the benet of accessory
cones really depends on the size of the canal and its apical shape. Lower
257
Fig. 30. Tooth No. 19 showing 90 apical curve. (A) Preoperative radiograph. (B)
Postoperative radiograph.
258
Fig. 31. Tooth No. 31 with C-shaped canal. (A) Preoperative radiograph. (B) Postoperative
radiograph.
Fig. 32. Tooth No. 32 with severe canal curvature. (A) Preoperative radiograph. (B) Working
length radiograph. (C) Postoperative radiograph.
260
Fig. 32 (continued )
anterior teeth with narrow canals did not seem to benet from the use
of accessory cones. Narrow canals were adequately obturated by the use
of one master cone without accessory cones. Alternately, upper or lower
canines or bicuspid with large canals showed a better obturation when
accessory cones were used compared with canals in which only one master
cone was used. These teeth also showed a dense obturation in the apical
third and in the rest of the canal, especially where isthmuses or irregularities
were present.
Using a plugger after the condenser seemed to be associated with a more
homogeneous obturation and better adaptation to the canal walls. Also, the
use of the plugger seemed to reduce the formation of voids within the gutta
percha lling.
The technique, using MicroSeal or Caulk-Densply ISO noncolor gutta
percha cones, seemed to be associated with the lling of lateral canals,
irregularities, isthmuses, and anastomoses in a high number of cases. In fact,
cross-sections from 12 of 16 specimens showed obturation material owing
into the intricacies of the root canal system.
According to the preclinical test and the authors clinical experience, it is
important to point out that the inappropriate use of the condenser may
261
Fig. 33. Tooth No. 14 exhibiting apical bifurcation. (A) Preoperative radiograph. (B)
Radiograph after the rst obturation showing ve canals and lling material between the
two palatal canals. (C) Working length determination of the sixth canal. (D) Postoperative
radiograph showing six separate canals and six separate foramina.
262
Fig. 33 (continued )
Clinical cases
The clinical cases presented in Figs. 29 through 33 were performed using
Caulk-Densply ISO noncolor gutta percha master and accessory cones.
Fig. 33 (continued )
264
References
[1] Naidorf IJ. Clinical microbiology in endodontics. Dent Clin N Am 1974;18:32944.
[2] Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors aecting the long-term results of
endodontic treatment. J Endod 1990;16:498.
[3] Gutmann JL. Clinical, radiographic and histologic perspectives on success and failure in
endodontics. Dent Clin N Am 1992;36:379.
[4] American Association of Endodontists. Appropriateness of care and quality assurance
guidelines. Chicago: American Association of Endodontists; 1994.
[5] Kersten HW, Wesselink PR, Thoden van Velzen SK. The diagnostic reliability of the
buccal radiograph after root canal lling. Int Endod J 1987;20:20.
[6] Gutmann JL. The dentin-root complex: anatomic and biologic considerations in restoring
endodontically treated teeth. J Prosthet Dent 1992;67:458.
[7] Allison DA, Weber CR, Walton RE. The inuence of the method of canal preparation on
the quality of apical and coronal obturation. J Endod 1979;5:298.
[8] Gutmann JL, Hovland EJ. Problems in root canal obturation. In: Gutmann JL, Dumsha
TC, Lovdahl PE, Hovland EJ, editors. Problem solving in endodontics. 3rd edition.
St Louis (MO): Mosby; 1997. p. 12355.
[9] Berry KA, Primack PD, Loushine RJ. Nickel-titanium versus stainless steel nger
spreaders in curved canals. J Endod 1995;21:221.
[10] Goodman A, Schilder H, Aldrich W. The thermomechanical properties of gutta-percha. II.
The history and molecular structure of gutta-percha. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1974;37:954.
[11] Speier MB, Glickman GN. Volumetric and densitometric comparison between nickel
titanium and stainless steel condensation. J Endod 1996;22:195.
[12] Gutmann JL, Witherspoon DE. Obturation of the cleaned and shaped root canal system.
In: Cohen S, Burns RC, editors. Pathways of the pulp. 7th edition. St. Louis (MO): Mosby;
1998. p. 258361.
[13] Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg 1984;58:589.
* Private Practice, San Francisco Endodontics, 500 Spruce Street #204, San Francisco,
CA 94118.
E-mail address: witewong@hotmail.com
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.10.002
266
Eect or success
No eect on success
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
These criteria are presented in order of decreasing frequency at which time they were
investigated to correlate with endodontic failures.
Data from Refs. [731].
267
268
269
270
271
training and experience of the clinician. The apical extent of the obturation
is always well dened. Overextension of gutta-percha occurs when there is
no apical seal of the root canal system [16]. When this occurs, the obturated
gutta-percha sometimes can be retrieved through the root canal system and
removed from the periapical tissues. Occasionally, however, removal of the
extended gutta-percha results in the disarticulation of the extruded guttapercha mass and may require surgical intervention. Iatrogenic procedural
errors such as transportations, ledges, separated instruments, and perforations contribute to the inability to retreat the system successfully.
Therefore, canals with severe curvatures, dilacerations, calcications, ledges,
and iatrogenic procedural errors may result in endodontic microsurgery.
Finally, when making the decision to retreat or perform microsurgery,
the cooperativeness of the patient must be considered. The clinician also
must be aware of the patients desires, expectations, inuences of time, and
nancial obligations. Furthermore, all alternative treatment plans and the
overall prognosis must be discussed before treatment. After all the data has
been considered and discussed, the patient then can make an informed
decision about retreatment, microsurgery, or possible extraction. The ability
of the operator also must be evaluated. This is extremely important because
several retreatment techniques require training and experience and should
not be attempted otherwise. Therefore, the clinicianwhether general
practitioner or specialistmust evaluate each case and assess the operators
capability for treatment or referral accordingly.
Fig. 2. (A) Preoperative radiograph of abscess in tooth before treatment. (B,C) Initial
examination with probing depths. (D) Examination with microscope and capillary tip to locate
vertical fracture.
272
Fig. 3. Use of ultrasonic device to reduce cement and retention of cast post.
273
Fig. 4. (A) Preoperative radiograph with clinical crown and post broken at the gingival margin.
(B) Placement of tubular taps. (C) Placement of extraction pliers. (D) Postoperative radiograph.
(Courtesy of Dr. William Goon.)
removal of any post (Fig. 3) [5]. However, caution must be observed when
using either of these instruments. In a preliminary study at the University of
the Pacic School of Dentistry [49], the use of piezoelectric ultrasonics
without the use of a coolant such as water resulted in a bony dehiscence.
Therefore, it is recommended that the use of ultrasonics or rotosonics be
used in conjunction with a constant, irrigating, and coolant such as water.
Occasionally the post can break and cause obstructions in the canal,
which results in unforeseen complications [20,44]. Also, sonic vibration may
not be enough to retrieve posts from the root canal system. Therefore,
devices have been made to add forces along the long axis of the tooth to
enhance post removal [5,20,43,44]. These devices are the Gonon Post Puller,
the Ruddle Post Removal System, and the Masserann Kit. The Gonon Post
Puller and Ruddle Post Removal System (SybronEndo, Orange, California)
are equipped with trephine burs that allow for the milling of the coronal
1 mm to 3 mm of the post itself, and have corresponding-sized tubular taps.
Rubber cushions are placed on the taps before mechanical threading of the
274
Fig. 4 (continued )
post. The taps are screwed with a counterclockwise motion onto the post
until a snug t is obtained. The rubber cushions then are pushed down onto
the functional biting surface of the tooth. The post removal pliers are placed
with the extracting jaws engaged into the tap and on top of the rubber
cushion for support. The instrument is held rmly, while the screw is turned
to open the jaws of the pliers, causing a build-up of pressure. As a result, the
screw is dicult to turn. The clinician should monitor the cushion on the
tooth and either pause a few seconds or place an ultrasonic on the tap, use
the vibrations, and loosen the cement. The combination will allow for future
turning of the screw and eventual removal of the post coaxial to the root
(Fig. 4). The Masserann Kit also uses a trephine bur; however, one size
larger than the post should be selected. The bur should be placed around the
post instead of on the post [20,44]. This larger trephine bur removes excess
dentin supporting the post for approximately 3 mm into the orice of the
canal wall. Afterward, a trephine bur one size smaller than the post is
selected. It is used with a slow-speech latch attachment to screw into the
post. The post then can be removed with a counterclockwise motion (Fig. 5).
In addition, the Masserann Kit also has an extractor that makes use of
275
Fig. 4 (continued )
a mechanical device to grasp the post. Ultrasonic vibration also can aid in
the retrieval of the post, as mentioned above [5,6]. The disadvantage of the
Masserann Kit is the initial unwarranted removal of excess dentin from
around the post.
276
Fig. 4 (continued )
examination and the quality and extent of the lling material. Table 2
summarizes considerations with regard to the elimination of gutta-percha in
the canal. The quality of the obturation must be identied. The fastest way to
retreat a canal is to pull out the gutta-percha [29]. This is especially true when
the canal is not condensed well [16]. Using any type of forceps or a Hedstrom
le can remove the lling material immediately. However, when the canal is
well condensed, it may necessitate the use of other instruments and techniques
to facilitate removal. Before the use of these techniques, the extent of the lling
material and the canal curvatures must be noted. Removal of the coronal
portion of the gutta-percha can be achieved with heat caries such as the TouchN-Heat (Kerr Corp., Glendora, California) or System B (Analytic Endodontics, Orange, California). Gates Glidden burs (Dentsply Maillefer, Ballaigues,
Switzerland) also are quite eective in the removal of the coronal portion of
the lling material. Recent studies [5054] have demonstrated the successful
use of nickel-titanium rotary les as well. Once the coronal portion of the
lling material has been removed, other techniques and devices then can be
employed readily.
277
Fig. 5. (A) Preoperative radiograph of separated post in lower incisor. (B) Depth of
trephination and use of Masserann Kit. (C) Postoperative radiograph of post removed.
(Courtesy of Dr. William Goon.)
Solvents have been used in the past to soften and dissolve gutta-percha
[16,5558]. However, all solvents are somewhat toxic to patients and should
be used with caution [55,57]. Solvents available for dissolution of guttapercha lling material are as follows: (1) chloroform, (2) eucalyptol, (3)
xylene, (4) methylechloroform, (5) halothane, (6) turpentine oil, (7) pine
needle oil, and (8) white pine oil. Chloroform is the most commonly used
solvent, due its eectiveness of dissolution [55,57,58]. It also is relatively
inexpensive and easy to use. When small, underprepared and curved canals
need negotiation, chloroform and small K-type les are best suited. The
sequential technique involves relling of the created reservoir in the canal
orice with drops of chloroform and picking into the dissolving guttapercha while ling with a size 10, 15, and 20 stainless steel le. This is
continued until the terminus is negotiated, after which all solvents should be
discontinued. Sequentially larger K-type les then are inserted into the canal
until all the gutta-percha mass is removed.
278
Fig. 5 (continued )
Researchers have reported that the newer nickel-titanium rotary instruments can facilitate the removal of gutta-percha in the canal [5054].
Caution should be taken when using rotary les around curvatures and
underprepared canals, however, because disarticulation can occur, resulting
in complications of the retreatment. Nevertheless, the use of stainless steel
hand les, with and without the use of solvents, has proved to be more
eective in complete removal of the lling material from the canal wall
[50,5254,59]. Moreover, the use of the surgical operation microscope has
been documented to improve the entire removal of gutta-percha from the
canal walls (Fig. 6) [59]. Chloroform unfortunately is classied as a beta-2
carcinogen [55,57]. Eucalyptol, an alternative, is less irritating than is
Table 2
Considerations for gutta-percha removal
Condensation
Shape of canal
Length
Pull out
Dissolve
Poor
Straight
Overextended
Well
Curved
Incomplete
279
Fig. 5 (continued )
chloroform and has an antibacterial eect [55,57]. It is, however, a lesseective gutta-percha solvent and must be heated to improve the solubility
of the gutta-percha mass.
The geographic location at which the endodontic therapy was performed
can aid in the decision of the retreatment. Pastes and cements can be
grouped into categories of soft and hard setting as well as impenetrable and
irremovable [5]. Pastes that often are found in root canals performed in
Russia, Eastern Europe, and the Pacic Rim pose complications due to the
hardness of the material [5], whereas pastes and cements that are used in the
United States are usually soft and can be removed readily [5]. The extent of
the lling material is again of the utmost importance. Usually the coronal
portion of the canal is obturated with the paste or cement, leaving the
middle and apical portion of the canal free of obstruction. However, one
must commonly deal with ledges, transportations, and calcications.
Disintegration of the coronal portion of the paste or cement can be
enhanced with piezoelectric ultrasonic vibrations [5,6,60,61]. Use of
a microscope also will facilitate removal of the lling material in the
straight portion of the canal. The use of ultrasonic vibrations will allow for
280
Fig. 6. (A) Preoperative radiograph of incomplete failing root canal. (B) Postoperative
radiograph of root canal fully treated after removal of the silver point gutta-percha, and
localization of the second mesial canal with the aid of the microscope.
281
Fig. 7. (A) Preoperative radiograph of an abscessed molar with a paste ll. (B) Postoperative
radiograph revealing second mesial buccal canal. The Quantec le and ultrasonics were used to
remove the paste ll.
282
Fig. 8. (A) Preoperative radiograph of a root canal failure with silver points. (B) Radiograph of
one silver point separated in the apical third. (C) Use of the twisted Hedstrom technique. (D)
Radiograph of silver point retrieval. (E) Postoperative radiograph.
a fulcrum to elevate the silver point out of the canal. Too often, the operator
will pull straight upward to mimic a post removal and the silver cone
disarticulates into the canal, resulting in unforeseen complications [5,16,27].
If the silver point has tension and resistance, then the use of ultrasonics on
the forceps for an indirect vibration can help to loosen the point and remove
the obstruction. Placement of ultrasonics directly on a silver cone will
disintegrate the material, and should be avoided [5,16,27,45].
When the obstructed silver point fractures, the object must be located
with an exposed radiograph and bypassed with K-type les. Use of smalldiameter 08 and 10 les along with a chelating agent will assist in the task. A
radiograph should be exposed once the terminus has been negotiated. Upon
negotiation of the apical foramen, sequential enlargement of the canal wall
is obtained. The operator must increase the size of the canal until it is
possible to bypass the impediment with Hedstrom les on two to three sides.
Twisting the handles, as well as the positive rake angles of the instrument,
will make it easier to grasp the obstruction from the canal [5]. A hemostat
can be used to grasp the le handle. A cotton roll is then positioned for
283
Fig. 8 (continued )
leverage and the hemostat is rotated over it to remove the silver point.
Another radiograph is exposed to ensure that the obstructed lling material
was removed (Fig. 8).
When an object cannot be bypassed or the silver point demonstrates
a larger diameter, then extracting devices such as the post removal systems
or the Endo Extractor Kit (Kerr Corp., Glendale, California) can be used
Fig. 8 (continued )
285
Fig. 9. (A) Preoperative radiograph of failing endodontic treatment with Thermal. (B)
Successful retreatment of the case using indirect ultrasonic vibration to remove the metal cores.
[43]. The Endo Extractor Kit has four trephine burs that correlate to les
with dierent diameter sizes. The use of cyanoacrylate adhesives aids in the
adhesion of the silver point to the extractor. Silver points are soft and can
erode with mechanical manipulation from trephine burs. Therefore,
choosing the exact trephine is extremely important. The trephine bur
removes approximately 3 mm of surrounding dentin. An extractor with
adhesive in the cannula is selected and placed over the object. After the
adhesives are set, the extractor is checked for resistance; ultrasonic vibration
can ensure the removal of the obstruction, as discussed earlier.
Thermal obturators (Dentsply, Tulsa Dental, Tulsa, Oklahoma) are
either metal or plastic carriers of gutta-percha. Carrier-based obturators
originally were designed with metal carriers [62]. The manufacturer has since
changed the carrier to plastic, which, unfortunately, is more dicult to
remove. Occasionally, in a few number of cases, a metal obturator will
present itself as the original obturation material. The metal obturator has
cutting utes that entangle the surrounding gutta-percha and make it more
dicult to retrieve and remove the obstacle [62]. The rake angles also will
present a problem with retrieval as they can engage the dentinal wall [5]. The
coronal portion of the canal and obturator should be accessed using the
post-removal techniques described above. The metal obturator can be
286
287
[9] Barbakow FH, Cleaton-Jones P, Friedman D. An evaluation of 566 cases of root canal
therapy in general dental practice. II. Postoperative observations. J Endod 1980;6:485.
[10] Bender IT, Seltzer S, Turkenkop W. To culture or not to culture? Oral Surg 1964;18:527.
[11] Frajich SR, Golber F, Massone EJ, Cantarini C, Artaza LP. Comparative study of
retreatment of Thermal and lateral condensation endodontic llings. Int Endod J 1998;
31(5):354.
[12] Grahnen H, Hansson L. The prognosis of pulp and root canal therapy: clinical and
radiographic follow up examinations. Odontol Rev 1961;12:146.
[13] Grossman LI, Shepard LI, Pearson LA. Roentgenologic and clinical evaluation of
endodontically treated teeth. Oral Surg 1964;17:368.
[14] Harty FJ, Parkins BJ, Wengraf AM. Success rate in root canal therapy: a retrospective
study of conventional cases. Br Dent J 1970;70:65.
[15] Heling B, Tamse A. Evolution of the success of endodontically treated teeth. Oral Surg
1970;30:533.
[16] Ingle JI. Endodontics. 3rd edition. Philadelphia: Lea and Febiger; 1985.
[17] Jokinen MA, et al. Clinical and radiographic study of pulpectomy and root canal therapy.
Scand Dent Res 1978;86:366.
[18] Lin LM, Skribner JE, Gaengler P. Factors associated with endodontic failures. J Endod
1992;18:625.
[19] Kerekes K, Tronstad L. Long-term results of endodontic treatment performed with
a standardized technique. J Endod 1979;5:83.
[20] Morse DR, et al. A radiographic evaluation of the periapical status of teeth treated by the
gutta percha-Eucha percha endodontic method: a one year follow up study of 458 root
canals. Oral Surg 1983;55:607.
[21] Pekruhn RB. The incidence of failure following single-visit endodontic therapy. J Endod
1986;12:68.
[22] Petterson K, et al. Endodontic status and suggested treatment in a population requiring
substantial dental care. Endod Dent Traumatol 1989;5:153.
[23] Rawskii AA, Brehmer B, Knutsson K, Petersson K, Reit C, Rohlin M. The major factors
that inuence endodontic retreatment decisions. Swed Dent J 2003;27(1):23.
[24] Selden HS. Pulpal periapical disease: diagnosis and healing: a clinical endodontic study.
Oral Surg 1974;37:271.
[25] Setlzer S, Bender IB, Turkenkopf S. Factors aecting successful repair after root canal
therapy. J Am Dent Assoc 1963;67:651.
[26] Smith CS, Setchel DJ, Harty FJ. Factors inuencing the success of conventional root canal
therapya ve year retrospective study. Int Endod J 1993;26:321.
[27] Stabholtz A, Friedman S, Ramse A. Endodontic failures and retreatment. In: Cohen S,
Burns RC, editors. Pathways of the pulp. 6th edition. St. Louis: Mosby-Year Book; 1994.
[28] Storms JL. Factors that inuence the success of endodontic treatment. J Can Dent Assoc
1969;35:83.
[29] Strindberg LZ. The dependence of the results of pulp therapy on certain factors: an analytic
study based on radiographic and clinical follow-up examination. Acta Odontol Scand 1956;
14(Suppl 21).
[30] Swartz DB, Skidmore AE, Grin JA. Twenty years of endodontic success and failure.
J Endod 1983;9:198.
[31] Zeldow BJ, Ingle JI. Correlation of the positive culture to the prognosis of endodontically
treated teeth: a clinical study. J Am Dent Assoc 1963;66:9.
[32] West JD. Endodontic failures marked by lack of there-dimensional seal. Endod Rep 1987;
Fall/Winter: 912.
[33] Alves J, Walton R, Drake D. Coronal leakage: endotoxin penetration from mixed bacterial
communities through obturated, post-prepared root canals. J Endod 1998;24(9):587.
[34] Torabinejad M, Ung B, Kettering JD. In vitro bacterial penetration of coronally unsealed
endodontically treated teeth. J Endod 1990;126:566.
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[35] Wu MK, Pehlivan Y, Kontakiotis EG, Wesselink PR. Microleakage along apical root
llings and cemented posts. J Prosthet Dent 1998;19(3):264.
[36] Simon JHS, Glick DH, Frank AL. The relationship of endodontic-periodontic lesions.
J Periodontol 1972;43:202.
[37] Vertucci FJ. Root canal morphology of mandibular premolars. J Am Dent Assoc 1978;
97:47.
[38] Vertucci FJ. Root canal morphology of maxillary second premolar. Oral Surg 1974;38:
456.
[39] Ruddle CJ. Microendodonitc analysis of failure: identifying missed canals. Journal Calif
Dent Assoc 1997;16:52.
[40] Abbott PV. Incidence of root fractures and methods used for post removal. Int Endod
J 2002;35(1):63.
[41] Altshul JH, Marshall G, Morgan LA, Baumgartner JC. Comparison of dentinal crack
incidence and of post removal time resulting from post removal by ultrasonic or mechanical
force. J Endod 1997;23(11):683.
[42] Angmar-Mansson B, Omnell KA, Rud J. Root fractures due to corrosion. Odontol Rev
1969;20:245.
[43] Goon WWY. Managing the obstructed root canal space: rationale and technique. Journal
Calif Dent Assoc 1991;19:51.
[44] Masserann J. The extraction of instruments broken in the radicular canal; a new technique.
Actual Odontostomatol 1959;47:265.
[45] Glick DH, Frank AL. Removal of silver points and fractured posts by ultrasonics.
J Prosthet Dent 1986;55:212.
[46] Machtou P, Sarfati P, Cohn AG. Post removal prior to retreatment. J Endod 1989;15:11.
[47] Masserann J. The extraction of posts broken deeply in the roots. Actual Odontostomatol
1966;75:329.
[48] Yoshida T, Gomyo S, Iroh T, Shibata T, Sekine I. An experimental study of the removal of
cemented dowel-retained cast cores by ultrasonic vibration. J Endod 1997;23:4.
[49] Gluskin AH. Preliminary study on the eect of heat from ultrasonic preparation on the
buccal cortical bone during post and instrument removal. University of the Pacic; 2003.
[50] Barrieshi-Nusair KM. Gutta-percha retreatment: eectiveness of nickel-titanium instruments versus stainless steel hand les. J Endod 2002;28(6):454.
[51] Betti LV, Bramante CM. Quantec SC rotary instruments versus hand les for gutta-percha
removal in root canal retreatment. Int Endod J 2001;34(7):514.
[52] Imura N, Kato AS, Hata GI, Uemura M, Toda T, Weine F. A comparison of the relative
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Int Endod J 2000;22(4):361.
[53] Sae-Lim V, Rajamanickam I, Lim BK, Lee HL. Eectiveness of Prole.04 taper rotary
instruments in endodontic retreatment. J Endod 2000;26(2):100.
[54] Valois CR, Navarro M, Ramos AA, De Castro AJ, Gahyva SM. Eectiveness of the
Prole.04 Taper Series 29 les in removal of gutta-percha root llings during curved root
canal retreatment. Braz Dent J 2001;12(2):95.
[55] Kaplowitz GJ. Evaluation of gutta percha solvents. J Endod 1990;16:539.
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retreatment. Braz Dent J 2002;12(3):208.
[57] Tamse A, Unger U, Metzger Z, Rosenberg M. Gutta-percha solventsa comparative
study. J Endod 1986;12:8.
[58] Wilcox LR. Endodontic retreatment with halothane versus chloroform solvent. J Endod
1995;21(6):305.
[59] Baldassari-Cruz LA, Wilcox LR. Eectiveness of gutta-percha removal with and without
the microscope. J Endod 1999;25(9):627.
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instrumentation. J Endod 1987;13:6.
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[61] Ruddle CJ. Microendodonitcs: eliminating intracanal obstructions. Dentistry Today 1996;
15:44.
[62] Becker TA, Donnell JC. Thermal obturation: a literature review. Gen Dent 1997;45(1):46.
[63] Bertrand MF, Pellegrino JC, Rocca JP, Klinghofer A, Bolla A. Removal of Thermal root
canal lling material. J Endod 1997;23:1.
[64] Wolcott JF, Himel VT, Hicks ML. Thermal retreatment using a new SytemB technique
or a solvent. J Endod 1999;25(11):761.
As with any dental treatment, procedural mishaps can occur during root
canal therapy. One such occurrence is the perforation of a root or pulpal
oor. When this occurs, the most important step is to seal this perforation as
quickly as possible, avoiding potential contamination from surrounding
tissues. If the perforation occurs in a general dentists oce, the dentist should
contact the local endodontist and request perforation repair on that same day.
After a perforation occurs, the goals are to sterilize (decontaminate) the site
and then seal the perforation. The material most widely used in endodontics
to seal perforations is mineral trioxide aggregate (MTA; Dentsply
Dental,York, Pennsylvania). MTA is extremely biocompatible, and it has
been shown histologically that osteoidlike material grows right into MTA [1].
Before placing MTA over a perforation site, the area should be copiously
irrigated with sodium hypochlorite. This irrigant is the one most commonly
used in endodontics and will help to clean the site.
Full-strength sodium hypochlorite is 5%, but most practitioners use
a diluted form that is mixed with approximately 50% water. The diluted
solution of sodium hypochlorite is as eective as the full-strength solution
for cleansing, with less potential toxicity.
After the perforation site has been soaked with sodium hypochlorite
for approximately 5 minutes, hemostasis and a barrier must now be
achieved. Even though MTA sets in the presence of moisture, as dry a site as
possible should rst be established because MTA (when mixed into
a sandy slurry) is dicult to manipulate and to place. A physical barrier
must be achieved at the perforation site to prevent MTA from being packed
into the bone or through the pulpal oor into the furcation site.
To achieve hemostasis and a physical barrier, there are several materials
available, including various collagen-type materials such as collatape
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292
Fig. 2. Perforation sealed same day with calcium sulfate and MTA.
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294
Fenton, Missouri). The S-Kondensers come in three sizes and are doubleended, with one side made of stainless steel and the other end made of
nickeltitanium. The proper sized S-Kondenser is chosen before the calcium
sulfate is mixed, depending on the size of the perforation. After placement,
the calcium sulfate will set over the next minute or so to a stonelike
consistency. The barrier is now in place and MTA is ready to be placed.
295
MTA has a much longer working time than calcium sulfate and if it
appears too dry, it can simply be rehydrated with sterile water or anesthetic
solution. Originally, MTA powder was gray in color and when mixed,
looked like sand and hardened to a concretelike consistency. When sealing
a perforation in the cervical portion of an anterior tooth, this gray MTA
was not esthetic. Therefore, MTA is now white and the manufacturer claims
there are no changes in the physical properties, but mixing it tends to be
a bit more technique sensitive. White MTA is creamier when mixed and a
little more dicult to manipulate but sets as hard as the original, gray
MTA. MTA is placed using the S-Kondensers and abuts to the barrier
that is already in place. MTA sets in the presence of moisture, so the
recommendation is to place a moist cotton pellet on top of the MTA and
to ll the access with a temporary lling material (eg, cavit; ESPE,
Norristown, Pennsylvania). MTA will set over the next several hours under
the moist cotton pellet, so at the next appointment, when the tooth is
accessed, MTA will be fully set and the tooth can be permanently restored.
There can be additional problems when a perforation occurs, in that it can
prevent renegotiating the canal if the perforation is in the canal or very
close. In these cases, it is paramount to try to keep the canal patent and
296
perhaps leave a le or paper point in the canal while using MTA so as not to
block the canal.
Clinical cases
Case 1
Perforation made with an overly aggressive post bur [3] (Figs. 13). This
perforation was sealed almost immediately, using a barrier of calcium
sulfate and MTA. The 3-year follow-up shows no signs of bone loss in the
furcation and no clinical depth greater than 2 mm.
297
Fig. 10. Calcium sulfate placed as an apical barrier and obturated with gutta percha.
Case 2
Perforation occurred during retreatment by one endodontist and was
referred to a second endodontist after several weeks (Figs. 4 and 5). This
perforation was through the pulpal oor, and this situation along with
the amount of time between the perforation occurring and being sealed
(allowing for contamination) decreased the prognosis for this case [4]. The
aforementioned technique was performed, using calcium sulfate as a barrier
and MTA to seal the perforation. The follow-up radiograph shows that this
case was successful, with furcal bone intact and no periodontal probing
depth greater than 2 mm.
298
Case 3
Retreatment case of a mandibular bicuspid with an existing perforation
from the rst endodontic treatment that most likely occurred while the
practitioner was looking for an additional canal (Figs. 68).
The preoperative radiograph for the retreatment shows bone loss on the
lateral side of the root due to the perforation and shows a periapical lesion
due to the fact that an untreated canal existed [5]. What makes this case even
more challenging is that while sealing the perforation on the lateral side of
the root in the midroot region, the clinician must be careful not to block the
299
Fig. 12. Maxillary incisor with blunderbuss apex and thin walls.
canal with the barrier material, especially because there is also a second
canal that needs to be negotiated for the rst time. For this reason, collatape
was chosen as the barrier material, which can more easily be manipulated
and packed through the perforation while maintaining the patency of the
canals. Collatape comes in strips of collagen-type material that the
clinician folds into a small piece and, with the S-Kondensers, packs it
through the perforation site into the surrounding bony space. This collagen
membrane resorbs, so it is acceptable to be extruding into the surrounding
bone/tissues of a tooth. The missed canal was located after the gutta percha
was removed from the other canal and both canals were treated. While in
the process of warm vertical obturation, the gutta percha was removed
300
Fig. 13. Physical barrier of calcium sulfate beyond apex and MTA in apical third of canal.
apical to the perforation site, making room to pack the collatape out
through the perforation, and then a layer of MTA was placed to seal o the
site and the other canals were obturated with warm gutta percha. A 1-year
radiographic follow-up shows healing of both the periapical and the lateral
lesions, with no periodontal probing depth greater than 2 mm.
One-step apexication
Another use for the barrier/MTA technique is for one-step apexication
cases. In the past, cases with open apices were often treated over several
301
302
303
Clinical cases
Case 4
Figs. 911 show a maxillary central incisor with an open apex in which
calcium sulfate was placed and a rm apical stop manufactured. Instead of
MTA in this case, a master cone of gutta percha was placed with tug back,
conrmed radiographically, and then completed by removing all but the
apical 5 mm of gutta percha using the System B heat transfer unit (Sybron
Endo, Orange, California) and backlling with the Obtura II. A 1-year
radiographic follow-up shows intact periapical bone and no sign of
pathology.
304
Case 5
Figs. 1215 show a maxillary central incisor with a blunderbuss apex and
thinner walls than the previous case. A small periapical lesion is present. To
create a barrier, calcium sulfate was placed apically, extruding into the
periapical area but forming a physical barrier against which MTA can be
packed at the root end. MTA lls the apical 3 mm of the canal, and the
rest of the canal is obturated with warm gutta percha [6]. An often-asked
question is, Why not ll the entire canal with MTA? There is really no
benet to doing this because MTA is much more expensive and more timeconsuming to place than gutta percha. Radiographic follow-ups at 2 years
show complete healing periapically and no pathologic signs.
305
Fig. 18. After several placements of calcium hydroxide, still no calcic barrier apically.
Case 6
Maxillary central incisor with an open apex in which apexication
was originally attempted by multiple calcium hydroxide placements [7]
(Figs. 1619). After this failed attempt to create a calcic barrier, the
one-step apexication technique was performed, using calcium sulfate and
MTA. A radiograph conrms the calcium sulfate in place (sealing o the
apical tip of the root), MTA in the apical few millimeters of the canal, and
the nal gutta percha placement. A slight demarcation can be seen between
MTA and gutta percha, but the radiopacity is almost identical.
306
Fig. 19. One-step apexication with calcium sulfate, MTA, and gutta percha.
307
[2] Carr OB. Magnication and illumination in endodontics. In: Clarks clinical dentistry, vol. 4.
St. Louis (MO): Mosby; 1998. p. 114.
[3] Akkayan B, Gulmez T. Resistance to fracture of endodontically treated teeth restored with
dierent post systems. J Prosthet Dent 2002;87:4317.
[4] Pitt Ford TR, Torabinejad M, McKendry DJ, Hong CU, Karyiyawasam SP. Use of mineral
trioxide aggregate for repair of ircal perforations. Oral Surg 1995;79:75662.
[5] Lee SJ, Monset M, Torabinejad M. Sealing ability of mineral trioxide aggregate for repair
of lateral root perforations. J Endodon 1993;19:5414.
[6] Shabahang S, Torabinejad M. Treatment of teeth with open apices using mineral trioxide
aggregate. Pract Periodontics Aesthet Dent 2000;12:31520.
[7] Sheehy EC, Roberts OJ. Use of calcium hydroxide for apical barrier formation and healing
in non-vital immature permanent teeth: a review. Br Dent 1997;183(3):2416.
[8] Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate.
J Endodontics 1999;25:197205.
Private Practice, 8929 University Center Lane, Suite 209, San Diego, CA 92122, USA
b
Department of Endodontics, University of Pennsylvania School of Dental Medicine,
240 South 40th Street, Philadelphia, PA 19104-6030, USA
The modern dental oce in the information age of today bears little
resemblance to the oces built 20 or even 10 years ago. The focus of
providing superior and eective patient care remains the same, but the
method of delivery and presentation has changed thanks to improvements in
technology on many fronts. Most inuential in this change has been the
widespread use of computers and computerized peripherals in providing
dental treatment and educating patients about the treatment they are to
receive. The information age, which represents the use of computers to share
and maintain information, has had many inuences in the eld of dentistry,
especially in endodontics. These inuences have begun to change the daily
practice of dentistry by aecting the standard of care and, most apparent,
the overall design of the modern dental oce to allow the use of and to take
advantage of these technologic changes. Like putting the pieces of a complex
puzzle together, this article reviews the process of reaching the goal of
modernizing a new or existing endodontic oce.
Most of the advancements in the modern endodontic oce revolve around
the use of computers that act as hub between the various components. It is
not rare to nd a modern endodontic practice using computers to capture
digital video and still images of treatment, to take and store digital
radiographic images, and to chart the patients treatment information.
Computers in the dental practice are not a new occurrence. For many years,
computers have been used to schedule patients, store patient information, do
billing, and in more advanced cases, perform comprehensive charting. By
using a computer system to manage the information used by the practice,
greater eciency is achieved on many levels. The most important advances in
* Private Practice, 8929 University Center Lane, Suite 209, San Diego, CA 92122.
E-mail address: guessendo@mac.com
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doi:10.1016/j.cden.2003.10.004
310
the dental oce come with the software that manages all of the vital
information used in the practice. Computer programs that maintain patient
information, digital radiographs, and scheduling information are forms of
databases. Databases allow the storage of all types of digital information that
can be retrieved and stored with minimal cost and maximal eciency. Instead
of using wall space in an oce to store paper charts, a computer system uses
hard drive space in a computer to digitally store a patients information. Given
this design, a computer system allows instantaneous access of information,
whether it is looking up when a patient is scheduled or retrieving their chart
and associated radiographs. The gain in eciency easily can be seen on many
levels. Eventually, the days of searching through reams of patient charts will be
gone because the computer programs allow searching the oce database with
instantaneous and accurate results.
The key to a modern endodontic practices organization and ecient
operation revolves around the stability of the computers that run practice
management software programs and other peripherals. The computer
hardware available today has the speed, exibility, and capability to perform
just about any needed task in the dental oce. Whether it ranges from
creating documents, storing patient data in a practice management program,
or manipulating digital video and images, the hardware available to the
private practice endodontist or dentist is aordable and capable. Therefore,
choosing the appropriate hardware comes down to esthetics, cost, performance, and compatibility with peripherals and practice management
software. Some computer systems use more intuitive operating system
software and have greater stability (eg, the Apple Macintosh systems), which
translates to less cost of maintenance and less downtime. If ones knowledge
is minimal regarding computers and their related systems, seeking the advice
from a computer consultant is invaluable. A consultant can plan the
requirements within a certain budget to get the job done. The choice of
hardware is an important one: it can mean the dierence between a transition
full of ease/success and a constant headache. The specic hardware requirements will be dictated by the practice management software program, the
digital radiographic system, and the peripheral video equipment used.
Because the software program ties in all of these technologies, it is one of the
best places to start looking when deciding what is needed to upgrade to
a modern oce (Fig. 1).
Choosing a software program to manage the oce could be one of the
most important decisions to make when considering the transition to
a computerized oce. So many functions of the practice hinge on this choice
and there are a lot of oerings available. Considering how important the
tasks are that the program manages, it is clear why this decision has to be
made wisely. In an oce where everything is stored in the computer, the
entire oce is dependent on the computer program, the hardware on which
it runs, and the network that connects it all together. If the program is
inecient or incapable, then the dentistry practice will likewise be inecient
311
Fig. 1. Practice management software is the hub connecting and managing all other
technologies utilized in the endodontic practice.
312
camera and to link with a digital radiography program are essential. The only
way to get accurate information to make an informed decision is to talk to
users of dierent software programs, listen to their experiences, and visit their
oces. It is even more helpful to test the programs using a demonstration
copy because often it is dicult to get the full sense of a program when
a salesman is present. Time is needed to get a feel for the thought process
that a particular computer program uses. This thought process is the manner
in which information is entered, changed, searched for, and stored. Some
programs can be intuitive and simple, whereas others may be very complex
and do not interact in a predictable or commonsense manner. These
important attributes of a computer program can only be noticed when
enough time is spent using and understanding the system through either
a demonstration or training session. In this way, a clear decision can be made
as to the best system for the specic application. All dental practices are
dierent; an oce may not want to start immediately with digital charting but
want that capability in the future. The software will need to be able to support
this upgrade, so thinking ahead when reviewing the current and planned
features is important.
Because the computer program ties together the pieces of technology in
the oce, the choice of the software program should follow exactly the
technology goal of the practice. If digital charting is desired, then the
program will have to have the capability to be networked to allow access to
patient information from dierent locations in the oce. For example, the
front desk will work with and maintain the patient information while the
back oce will work with that patients chart for the day. The front desk
needs to know the treatment performed to properly collect the fees. Having
the infrastructure present to support these capabilities is a prerequisite. The
infrastructure includes the wires, power outlets, and other equipment needed
to perform certain functions. To have computers in the operatories linked to
share patient information, a computer network has to be present. Today,
there are dierent types of networks available: wired and wireless. A wired
network is the preferred method (which involves wires to be run to each
location where a computer is present) because it is the most robust method
of interconnecting computers. Wireless systems have tremendous exibility
in environments where wires cannot be placed due to feasibility or
economics. The current wireless systems do not have the speed capabilities
of the standard wires and are susceptible to interference issues, which make
them unacceptable in most dental practice settings. Therefore, planning is
required and a contractor needs to be employed run the wires to all needed
locations throughout the oce. It always is smart to plan ahead for
expansion by running extra wires that may be used in the future.
Computers have changed the landscape of digital imaging and its ease of
use in many environments including dentistry. Endodontics is one eld that
has taken advantage of this technologythe ability to document treatment
with digital still and video imaging. Endodontists often will want to take
313
314
Fig. 2. Computer monitor placement on the wall behind the patient for exible computer
viewing and input by the sta and/or doctor.
315
Fig. 3. Doctor and sta working shown with an operating microscope and integrated video
camera, displaying the video through a chairside computer station.
316
Fig. 4. Network connections between computers in the same oce, and between oces to
permit the sharing of patient and practice data.
317
318
Fig. 5. Digital xray system: wired sensor connected to a USB interface with the computer. The
exposed sensor produces an image on the computer display for viewing and manipulation.
because each root end can then be visualized over a series of angled digital
radiographic images before progressing. From a waste and materials-usage
standpoint, there are no chemicals to maintain or change, so digital
radiography has no per-use cost other than the storage space on the
computer that the digital image le requires. Also, with most systems using
newer image compression routines, the le sizes are extremely small relative
to the storage available. Digital radiography also has several sta, doctor,
and patient health benets because the radiation dose exposure is
signicantly decreased. Compared with the fastest E-speed lm that may
require a 20-millisecond exposure at 70kVp, the same quality image can be
obtained with a digital radiographic system using just 3 milliseconds of
exposure time with the same 70kVp, which is close to a seven-times decrease
in radiation exposure to the patient. Digital radiography allows the doctor
to more easily view the image and greatly facilitates educating the patient
because it allows a large screen-sized image to be viewed on the monitor.
The resolution of the current digital radiographic systems is very good,
greater than most computer screens can display. The image quality is mostly
determined, therefore, by the type of monitor or at panel that is used
because all systems have similar high-quality sensors and resolution
capability. For this reason, high-quality computer displays are an important
investment when considering the purchase of computer equipment for the
modern dental oce.
The benets of digital radiographic systems are clear, but it is the high
cost of the system that keeps most oces from making the change. In
addition, digital radiography must be used with a computer that controls the
radiographic system, so a computer is required in each operatory. To get
319
320
321
programs, and most dicult, keep up with the changes. What is advanced
today will quickly and inevitably be improved on in the near future. By
making the right decisions in software type and video and radiographic
systems, planning for the future is possible. By building a foundation that is
prepared to handle changes in computer demands, it is hoped that the
networking, wiring, and power infrastructure of the oce will not require
any changes for a long time. Computer hardware itself will need to be
upgraded over time as the demands of software and other systems always
seem to increase. The hardware needs to be able to eciently handle more
features as they are added. Fortunately, hardware development and updates
tend to be far ahead of the needs of current dental software and peripheral
demands.
Making the transition to the modern dental practice is expensive and
time-consuming but also protable and exciting. There is so much to learn
in this process and so much to keep up with because the technology changes
rapidly. Soon, all dental oces will be using digital radiographic systems,
video systems, and patient charting programs that use no paper
documentation. These features make up the modern dental oce of today
and of tomorrow. Going 100% paperless is not the best solution for all
practices, but the time is getting closer where this is increasingly becoming
a reality and an expectation of patients. As computer familiarity and the
sta knowledge base increases with the growing use of computers in society
overall, nding the oce personnel able to harness the eciency and power
of the technology in the dental oce will be easier, making this transition
a smooth one. Through careful planning and formation of a reasonable
technology goal, updating an old oce or creating a new modern
endodontic practice with the technologies of today can be an enjoyable
reality from which practitioners and their patients can benet.
324
Fig. 1. The mesiodistally directed radiograph indicates a attened distal root canal in
a mandibular rst molar. In the same tooth, the faciolingual direction of the routine radiograph
gives an impression of a round-shaped distal canal.
325
Fig. 2. The faciolingual direction of the routine radiograph gives an impression of roundshaped canal in a mandibular rst premolar. The mesiodistally directed radiograph indicates
a attened root canal in the same tooth.
Fig. 3. Cross-section of a mandibular rst premolar, indicating a long-oval and irregular root
canal. In the same tooth, the faciolingual direction of the routine radiograph may be mistakenly
recognized as a round-shaped canal because a mesiodistally directed radiograph is rarely
available clinically.
326
dimension N mm short of
dimension N mm short
dimension at working
dimension 1 mm short of
dimension 2 mm short of
dimension at working
dimension 1 mm short of
dimension 2 mm short
327
328
Table 1
Current concepts and guidelines determine the minimal nal working width at working length
from dierent publications
Author and references
Tooth
Maxillary
Centrals
Laterals
Canines
First premolars
Second premolars
Molars
MB/DB
P
Mandibular
Centrals
Laterals
Canines
First premolars
Second premolars
Molars
MB/ML
D
Grossman [17]
8090
7080
6060
3040
5055
305550
4050
4050
5055
3040
5055
305550
Tronstad [20]
Glickman and
Dumsha [19]
7090
6080
5070
3590
3590
3560
2540
3050
2540
2540
3560
80100
2540
2550
3570
3570
5070
3570
3570
2540
2540
3050
3050
3050
3545
4080
2540
2550
Weine [21]
3
3
3
3
3
3
3
3
sizes
sizes
sizes
sizes
sizes
sizes
sizes
sizes
3
3
3
3
3
3
3
3
sizes
sizes
sizes
sizes
sizes
sizes
sizes
sizes
329
330
on the canal wall surface. These phenomena can serve as an impacting factor
that induces a false estimation of the true canal dimension at working length
and other levels.
Instrument for determining initial working width
The rigidity, exibility, and tapering of the instrument used for determining IWW can aect accuracy. As mentioned previously, any tapering
discrepancy between the gauging instrument and canal may lead to an early
instrument engagement of the canal wall, altering the tactile sensation. In
addition, the rigid instrument in a curved canal also can lead to a false
tactility. During IWW determination, the combination of those aecting
factors can have a great impact on the accuracy. Understanding these factors
can minimize the underestimation of the IWW and maximize its accuracy.
Fig. 4. In a long-oval or at root canal, reaming and modied reaming actions will result in
incomplete debridement of the root canal system. The keyhole and dumbbell eects (B,C)
are typical pictures that demonstrate the unprepared parts of the root canal. Most NiTi rotary
instruments used with continuous reaming and modied reaming actions like the balanced
force technique and quarter-turn pull technique will lead to the same misadventures (AC).
Circumferential instrumentation can conform to the outline of the horizontal dimensions of the
root canal at dierent levels of the canal (D).
331
332
Fig. 7. A cross-section of incompletely prepared and lled canals demonstrates the complicated
situation of endodontic WW. Understanding the concepts and the techniques of endodontic
WW can minimize misadventures of incomplete instrumentation and a failed root canal
treatment.
ideal condition, especially for long-oval and attened root canals, they can
be cleaned and shaped properly with minimal mishaps of weakening,
stripping, or perforating the canal walls as shown in Fig. 4D. Circumferential preparation or instrumentation may have to be considered for these
cases to minimize incomplete cleaning of the root canal system. Most of the
NiTi rotary instruments provide a continuous reaming action that makes
the canal relatively circular in shape. Indiscriminate use of NiTi rotary
instruments alone for root canal cleaning and shaping may result in
incomplete cleaning of the root canal system and lead to failure of the
endodontic therapy (Fig. 5). Recent studies [10,12,1416] have indicated
that no current instrumentation technique was able to completely clean
dentin walls of the oval, long-oval, and attened root canals. The manual
crown down instrumentation technique, however, was more ecient and
eective in cleaning attened root canals than rotary instrumentation.
333
334
Summary
There has been minimal development of concepts, techniques, and
technology to measure IWW and to determine FWW accurately or
properly. Understanding the current concepts and techniques of WW can
reduce the underestimation of the MinIWW0 and apical MinIWW and
subsequent incomplete cleaning of the root canal system. The detailed
information regarding horizontal morphology of the root canal system can
help to solidify concepts and improve techniques of cleaning and shaping
the root canal system. Carefully maintaining the aseptic chain, using
adequate irrigating solutions to enhance ecacy, and cautiously applying
current concepts and techniques of WW may provide a better quality of
endodontic therapy for the patient.
References
[1] Haga CS. Microscopic measurements of root canal preparations following instrumentation. J Br Endod Soc 1968;2:41.
[2] Gutierrez JH, Garcia J. Microscopic and macroscopic investigation on results of
mechanical preparation of root canals. Oral Surg 1968;25:10816.
[3] Walton RE. Histological evaluation of dierent methods of enlarging pulp canal space.
J Endodon 1976;2:30411.
[4] Mauger MJ, Schindler WG, Walker WA. An evaluation of canal morphology at dierent
levels of root resection in mandibular incisors. J Endodon 1998;24(10):6079.
[5] Kerekes K, Tronstad L. Morphometric observations on the root canals of human molars.
J Endodon 1977;3(3):1148.
[6] Kerekes K, Tronstad L. Morphometric observations on the root canals of human
premolars. J Endodon 1977;3(2):749.
[7] Kerekes K, Tronstad L. Morphometric observations on the root canals of human anterior
teeth. J Endodon 1977;3(1):249.
[8] Gani O, Visvisian C. Apical canal diameter in the rst upper molar at various ages.
J Endodon 1999;25(10):68991.
[9] Wu MK, Barkis D, Roris A, Wesselink PR. Prevalence and extent of long oval canals in
the apical third. Oral Surg 2000;89(6):73943.
[10] Liu DT, Jou YT. A technique estimating apical constricture with K-les and NT
Lightspeed rotary instruments. J Endodon 1999;25(4):306.
[11] Levin JA, Liu DT, Jou YT. The accuracy of two clinical techniques to determine the size of
the apical foramen. J Endodon 1999;25(4):294.
[12] Weiger R, Lost C. Eciency of hand and rotary instruments in shaping oval root canals.
J Endodon 2002;28(8):5803.
[13] Wu MK, Barkis D, Roris A, Wesselink PR. Does the rst le to bind correspond to the
diameter of the canal in the apical region? Int Endodon J 2002;35(3):2646.
[14] Barbizam JVB, Fariniuk LF, Marchesan MA, Pecora JD, Sousa-Neto MD. Eectiveness
of manual and rotary instrumentation techniques for cleaning attened root canals.
J Endodon 2002;28(5):3656.
[15] Tan BT, Messer HH. The quality of apical canal preparation using hand and rotary
instruments with specic criteria for enlargement based on initial le size. J Endodon 2002;
28(9):65864.
[16] Wu MK, Wesselink PR. A primary observation on the preparation and obturation of oval
canals. Int Endodon J 2001;34:13741.
335
[17] Grossman L. Endodontic practice. 10th ediiton. Philadelphia: Lea & Febiger; 1986.
[18] Dummer PMH, McGinn JH, Rees DG. The position and topography of the apical canal
constriction and apical foramen. Int Endo J 1984;17:1928.
[19] Glickman GN, Dumsha TC. Problems in canal cleaning and shaping. In: Gutman L,
Dumsha C, Lovdahl, Hovland E, editors. Problem solving in endodontics. 3rd edition.
St Louis (MO): C.V. Mosby; 1997. p. 114.
[20] Tronstad L. Clinical endodontics. New York: Thieme; 1991.
[21] Weine FS. Endodontic therapy. 5th edition. St. Louis (MO): C.V. Mosby; 1996.
[22] Carter JM, Sorenson SE, Johnson RL, Teitelbaum RL, Levine MS. Punch shear testing of
extracted vital and endodontically treated teeth. J Biomech 1983;16:8418.
[23] Kuttler Y. Microscopic investigation of root apexes. J Am Dent Assoc 1955;50:54452.
[24] Walton RE, Torabinejad M. Principles and practice of endodontics. 3rd edition.
Philadelphia: W.B. Saunders; 2002.
Index
Note: Page numbers of article titles are in boldface type.
A
Apex locator(s), electronic, 45, 3554
frequency-dependent, 3738
accuracy of, 3841, 47, 48
operation with various
electrolytics, 4147
problems with using, 5051
suggestions for use of, 49
to detect root perforation, 48
use in primary teeth, 48
with additional functions, 38
history of, 3638
traditional-type, 3637
Apexication procedures, one-step, 300302
calcium sulfate in, 301302
clinical cases illustrating, 303306
mineral trioxide aggregate in,
301302
repair of root perforation and,
291307
Apical foramen, terminus of, gaining access
to, 275286
C
Calcium sulfate, for hemostasis and barrier,
in root canal therapy, 291293, 295
in one-step apexication, 301302
Cavity, access to, extension of, 217
preparation of, obturation of root
canal system and, 217
Collatape, for hemostasis and barrier, in
root canal therapy, 291293
Computers, as hub between oce
components, 309, 311, 315
choosing software program for, 310,
312
decision for, obtaining information
for, 311312
digital radiography systems and, 313,
317318, 319, 321
documentation of treatment using,
312313
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S011-8532(04)00026-6
338
Endodontics (continued )
retreatment versus
microsurgery, 267
removal of semisolid materials in,
275280
solid material removal in, 280286
Endodontics-only software, 311
G
Gutta percha, removal of, 275280
Gutta percha cones, obturation of root
canal system and, 204207, 211
of MicroSeal systems, 220, 221,
227231
Gutta percha heater, of MicroSeal systems,
221, 231232
I
Instruments, endodontic, nonsurgical
ultrasonic, 1934
for nonsurgical endodontics, 1314
K
K3 rotary nickel-titanium le system,
137157
authors experience with, 141143
clinical technique, 148156
assumptions for, 145148
les, 137, 138140
gauging of apex for, 154156
literature on, 143145
standard technique, variations on,
156157
L
LightSpeed System, 113135
instruments, design of, 113116
fracture of, 130
IAR, 119
maintenance and replacement of,
128130
MAR, 118, 119122
technique of, details of, 118127
principles of, 117118
M
Microscope, 13, 4
cost of, versus patient benet of, 18
endodontics and, 1118
in nonsurgical endodontics, 1118
procedures requiring, 1517
NiTiNOL alloy, 55
manufacturing of, 5758
339