roots

issn 1616-6345 Vol. 5 • Issue 1/2009

the international magazine of endodontics

1 2009

_working length
Endodontic success and
working length: thinking
three-dimensionally

_clinical
Nonsurgical therapy of
mucosal and cutaneous
fistulae
_trends
Ceramics-based sealers as
new alternative to currently
used endodontic sealers

RO0109_1-52.indd 1 3/5/09 11:33:15 AM

 An innovative
jump

The M two NiTi-system is an

®

innovative concept to efficiently

clean and shape even oval canals.

A simple procedure taking all

instruments to full working length,
eliminating the risk of ledges and
enabling irrigation with an ISO 30
cannula straight after the 2nd
instrument.

A real jump when it comes to saving

time and successful therapy.

an innovation in
efficiency, simplicity and safety

Want information ?

VDW GmbH · P.O.Box 830954 · 81709 Munich, Germany

info@vdw-dental.com · www.vdw-dental.com

Mtwo innovative jump A4.indd 1 27.02.2009 15:34:44

 roots _ contents I

Obturated canal

Detector wire
(PVC-covered electrical wire)

To power source

page 6 Figure 1. Schematic diagram of test tooth

page 12 page 18

I trends I trends
4 Endodontic success and working length: thinking 32 Nonsurgical therapy of mucosal and cutaneous fistulae
three-dimensionally _ Arnaldo Castellucci
_ E. Steve Senia

I research
I research
42 Ceramics-based sealers as new alternative to currently
12 The leakage resistance of endodontic fiber obturator used endodontic sealers
_ Gregori M. Kurtzman & J. A. von Fraunhofer _ Deyan Kossev & Valeri Stefanov

I trends I about the publisher

18 K3 rotary nickel titanium instrumentation: Blending 49 _ submissions
safety and efficiency
50 _ imprint
_ Gary Glassman

I trends
26 Answering two frequently asked clinical endodontic I on the cover
questions: How much taper? How do I troubleshoot my The cover image for this issue of Roots magazine is courtesy of
apex locator? Dr. Eric Herbranson, 3D Interactive Tooth Atlas, Brown and
_ Richard Mounce Herbranson Imaging, eHuman.com.

page 26 page 32 page 42

roots
1 _ 2009 I 03
RO0109_1-52.indd 3 3/5/09 1:14:12 PM
 I trends_ working length

Endodontic success and

working length: thinking
three-dimensionally
Author_ E. Steve Senia, U.S.A.

I
n the article “Endodontic success: it’s all about
the apical third” (Roots magazine, Vol. 4, Issue
1, 2008, pages 14–19), we introduced the
term working width (WW). Don’t be surprised
if you have never heard this term — it’s quite
new and warrants a brief description. WW is the
canal’s pre-instrumented diameter, adjacent and
coronal to the apical constriction (Fig. 1). I like this
term very much, because it is a valuable reminder
that canals are three-dimensional. Instrumenta-
tion should address a working length and a working
width. My last article focused on working width, this
article focuses on working length.
Definition of working length
There is considerable disagreement regarding ex-
actly where working length (WL) should terminate.
Let’s explore the reasons and try to make sense of it
all. The American Association of Endodontists’ Glos-
sary of Endodontic Terms states: “working length is
the distance from a coronal reference point to the
point at which canal preparation and obturation
should terminate.”1 Where is the disagreement? The
definition doesn’t tell us where WL should terminate.
Exactly where should it be? Our forefathers hotly
debated the question for many years, and the issue
appeared to be resolved. Unfortunately, WL is once
again embroiled in controversy.
Our forefathers concluded that instrumenta-
tion should end at the cementodentinal junction
(CDJ) (Fig. 1), which is approximately co-located
with the apical constriction. Most agree with that

Fig. 1_Root-end anatomy. Working

Width (WW), outlined in blue, is
the canal width coronal to the
constriction. If the average size
of a constriction is #30, a larger
instrument is required to clean
this area. Note that the CDJ (black
arrows) is co-located with the
constriction.

Fig. 2a_Photograph showing the

foramen, constriction and apex.

04 I roots 1_ 2009

RO0109_1-52.indd 4 3/5/09 1:09:38 PM

 Veraviewepocs 2D/3D

The Number One in Every Class

Whether your interest is digital panoramic, cephalometric or 3D imaging

– at J. Morita you always get the best device for the most precise dia-
gnoses. As a pioneer in volume tomography we are familiar with the high
requirements of diagnosticians. Our wide variety of devices and choice
of combinations provide you with the sharpest imaging of details down
Volume Size
to 80 µm. 40 mm x 40 mm
60 mm x 60 mm
From the first step, upgradable 2D devices, to the basic version Vera- 80 mm x 80 mm
viewepocs 3De and the high-quality X-Ray CT unit 3D Accuitomo 170, 100 mm x 100 mm
170 mm x 120 mm
one thing always remains unchanged: You obtain the highest imaging
quality from the lowest effective radiation dose and the shortest scan
times. Nothing is more elementary than the correct diagnosis.

Trust the number one in the class! We would be happy to advise you.
Phone +49 (6074) 836-0 or visit our website at www.jmoritaeurope.com

Thinking ahead. Focused on life.

RZ_Anz_Roentgenfamilie_A4_eng.in1 1 20.02.2009 13:13:21 Uhr

RO0109_1-52.indd 6 3/6/09 9:36:41 AM

location because the pulp makes dentin and the
periodontium makes cementum. Instrumentation
should remove pulp tissue and not invade the peri-
odontium. That’s not to say that I’m against passing a
patency file past the CDJ or even slightly beyond the
foramen. However, remember the formula, Area = p
(pi) times the radius squared. This means that a #15
(0.15 mm) patency file’s tip occupies only 5 percent
of the average foramen’s cross-sectional area (0.60
mm) and only 25 percent of the average constric-
tion’s area (0.30 mm)!2
I suspect patency files are used more for warning
of an impending ledge than for maintaining patency.
The downsides are the likelihood of a patency file
lacerating vital tissue beyond the constriction and
possibly causing postoperative pain in an asympto-
matic vital case. A clean cut of the pulp at its narrow-
est point (apical constriction) is a more biologically
acceptable approach. In necrotic cases it would likely
push infected material into the periapical tissue and
possibly cause a “flare-up.”
Termination point
Where to terminate WL (our clinical target) re-
quires two reference points. The first one is the coro-
nal reference point on the crown, and the second is in
the apical part of the canal. The AAE Glossary states
that a root canal is: “a passage or channel in the root
of a tooth extending from the pulp chamber to the
apical foramen.”1 Note that the foramen defines the
end of the canal. This narrows the choices for WL
to somewhere between the foramen and the CDJ/
constriction.
The Glossary positions the apical constriction
RO0109_1-52.indd 7
trends_ working length I
“usually 0.5 to 1.0 mm short of the center of the api-
cal foramen,” but positions the CDJ “ranging from
0.5 to 3.0 mm from the anatomic apex.”1 The last
word, apex, is very important. If the CDJ can be as
much as 3 mm from the apex, it means that the apex
is not a precise reference point for WL determination
and should not be used. Clearly, apex and foramen
can’t be used interchangeably, and evaluating the
quality of an obturation by its distance from the
apex is wrong.
A meaningful discussion of WL can only take
place when it is understood to be measured in mil-
limeters from the foramen and not the apex. So let’s
not talk about the apex because it’s irrelevant, and
let’s not pretend that the apex is the same as the
foramen. It’s all about the foramen, which is usually
not at the apex.2,3 Gutierrez and Aguayo3 examined
140 teeth with a scanning electron microscope. They
found no foramina located exactly at the apex, and
the average distance of the foramen from the apex
ranged from 0.2 mm to 3.8 mm. The foramen gives
a precise reference point for WL determination — the
apex does not.
If we use the foramen, rather than CDJ/constric-
tion or apex, as a firm reference point, we can really
narrow down the best locations for WL. I purposely
use the plural to emphasize the two acceptable loca-
tions — 0.5 mm from the foramen or 1.0 mm from the
foramen. Why not agree on a WL that ranges from
0.5 mm to 1.0 mm short of the foramen? I think that’s
reasonable, and here’s why. Let’s say that I believe WL
should be 0.5 mm short of the foramen, whereas you
think it should be 1.0 mm short of it. Could I say that
my choice is correct, whereas yours is not and your
Fig. 2b_A “perfect” obturation
“closing the door” against further
contamination from above; bacteria
apical to the gutta-percha are trapped
and destroyed.
Fig. 2c_WL short of the desired
location (constriction), but the WW is
correct and the door is closed.
roots
1 _ 2009 I 07
3/5/09 1:09:40 PM
 I trends_ working length
Fig. 2d_Distal canal of mandibular
molar cross-sectioned 1 mm from
apex. WL was correct, but WW was
not because the final instrument size
was too small. The case failed.
Fig. 2e_Example of a “closing the
door” obturation. Compare with
Figure 2d.
08 I roots 1_ 2009
RO0109_1-52.indd 8
treatment will fail? Of course not!
The body’s defenses
Let’s discuss WL further using a photograph of a
root end (Fig. 2a) and add an instrumented and obtu-
rated canal (Fig. 2b), closing the door and preventing
further bacterial contamination from above. Bacte-
ria apical to the gutta-percha are cornered with no
place to run. They are destroyed by polymorphonu-
clear leukocytes (PMN), and any remaining debris is
cleaned up by the macrophages.
Hypothetically, let’s now miss our WL by 1 mm
(short) (Fig. 2c). Just as in Figure 2b, the door has
been shut and the bacteria are trapped. What hap-
pens to the bacteria between the foramen and the
gutta-percha seal when the WL is perfect or 1 mm
short of that length? Same answer, the bacteria are
attacked and destroyed by the PMN — the major cir-
culating cell in the immune system, whose function
is to kill bacteria. (In fact, when the body encounters
infection, the production of PMN increases tenfold.)
Another body defense cell is the macrophage, whose
function is to clean up the debris4 — a task it does very
well — as evidenced by the rapid disappearance of
extruded root canal sealer.
Now let’s change the situation to where WL is per-
fect, but WW is not (Fig. 2d). There is a dramatic dif-
ference between what happens to the bacteria in a
correctly cleaned and filled canal (Fig. 2e) versus one
where necrotic tissue remains. When this happens,
the door is not shut since the root canal sealer can-
not replace the infected tissue. Bacteria feast on the
tissue and reproduce rapidly. Because the infected
pulp is 1 mm from the apex (Fig. 2d), the continuous
production of bacteria and their toxins exiting the
foramen was too much for the body defenses and
the case failed.
There seems to be a widespread belief that the
immune system behaves differently at the apex
compared to other places in the body. The apex is
not a mystery zone — the defense mechanisms there
are “alive and well” and fully functional. The mis-
understanding, I think, arises from the errant belief
that canals in necrotic cases lack a blood supply. This
is true — high up in the canal — but not within the
region associated with WL. This part of the canal is in
close proximity to a generous blood supply.
How to locate WL clinically
Now that we have decided that WL should range
from 0.5 mm to 1.00 mm from the foramen, how do
we find it? I believe electronic apex locators (EAL)
have contributed greatly in making WL determina-
tion more scientifically based. No longer do we have
to engage in the foolishness of evaluating a treat-
ment by the aesthetic proximity of obturating ma-
terials to the radiographic apex. It’s worth repeating:
the apex has nothing to do with WL — it’s all about
the foramen. This then begs the question — why are
the electronic devices called apex locators?
Apex locator is a poor name, and the manufactur-
ers should call them what they are — foramen (or
constriction) locators. I recommend we use elec-
tronic foramen locator (EFL) and get rid of the term
apex locator from here on.
During my teaching years, we evaluated ra-
diographic “dead-on the apex” obturations. When
the teeth were extracted or viewed during surgical
retreatment, the dead-on’s were overfills most of
the time. I had to constantly remind students of
this fact (and proved it during their training with
extracted teeth). Blasting through the constriction
to or slightly beyond the foramen and obturating to
that point for an aesthetically pleasing X-ray is not
scientifically justified.
Knowing the limitations of radiographs for WL
determination, let’s see how electronic foramen
locators provide greater accuracy. As with all elec-
tronic devices, carefully read the instructions. But
if they say that the activation of the “bells, lights
or whistles” tells you the file tip is at the apex, isn’t
that a problem? Since the apex is not the end of the
canal, exactly where is the tip? How do we solve
this dilemma and make EFLs clinically useful? Un-
fortunately, we have to do what the manufacturers
should have done. If the alarms indicate the tip is at
the apex but we think it’s at the foramen, we should
subtract 0.5 mm to 1.0 mm from the file insertion
length to get WL. If the alarm is indicating apex but
we believe the tip is actually at the constriction,
then we should use that for WL. And finally, if the
manual says that the bells, lights or whistles go off
at the constriction, you will have to confirm the ac-
curacy of that statement. You may have to do some
fine-tuning as you gain practical clinical experience
with your specific device. A little practice and careful
observations while using your EFL will be required.
The good news is that in spite of their shortcom-
ings, EFLs provide consistently better accuracy than
X-rays. They also should help resist the temptation
of indulging in “aesthetodontic” contests. In our
lectures and writings we could show X-rays of cases
that appear “short” (but are not) without worrying
3/5/09 1:09:41 PM
A NEW PARADIGM
IN CANAL SHAPING
The Twisted File is the first and only file to combine three unique and
proprietary processes to deliver unsurpassed strength and flexibility.

TWISTED DESIGN, NOT GROUND

R-PHASE HEAT TREATMENT TECHNOLOGY

ADVANCED SURFACE TREATMENT

SybronEndo Europe, Basicweg 20, 3821 BR Amersfoort, The Netherlands Tel: +31 33 4536 159 fax: +31 33 4536 153
email: endo@sybrondental.com ©2008 SybronEndo
 I trends_ working length
Fig. 3a_LightSpeedLSX™ NiTi about our work being judged inferior. All we would
rotary instruments with a very short have to do is advise the audience beforehand that
blade and non-cutting shaft.
all WL were 0.5 mm to 1.00 mm from the end of the
canal using the accuracy of an electronic foramen
locator rather than the inaccuracy of an X-ray.
Alternative technique for WL
determination
I give credit for this technique to Bill Wildey,
Fig. 3b_Length-marking rings on the the co-inventor of LightSpeed™ (Fig. 3a). Wildey
shank can be used as an alternative uses LightSpeedLSX™ instruments (Discus Dental,
to rubber endo stops (25 mm LSX). Culver City, Calif.) to fine-tune WL. He starts with
the estimated length given by the EFL; he then goes
1–2 mm beyond that length with the LSX rotating
in the handpiece. The small size of the LSX #20
blade usually passes easily through the constriction
because the average diameter of the constriction is
roughly #30. Depending on the actual diameter of
Fig. 3c_Length-marking rings on 21 the constriction (if one exists), the LSX #25 or #30
mm LSX. usually engages the walls of the constriction and
a “popping” sensation is felt when the blade goes
through the constriction. This tactile feedback gives
the exact location of the constriction and the desired
location of WL. The key is to advance the instruments
very slowly to feel what’s happening in the canal. If
a constriction is not present, the popping sensation
will be felt passing through the foramen.
_About the author roots
E. Steve Senia, DDS, MS, BS
Dr. E. Steve Senia earned a DDS degree from Marquette University
in 1963. He re-entered the Air Force (previously served as a pilot)
and completed a GPR residency. In 1969, he received a MS and
Certificate in Endodontics from Ohio State University. He served
in the Air Force and retired in 1981 as a colonel and chairman of
endodontics at Lackland AFB, Texas. He then became professor
and director of the Endodontic Postdoctoral Program at the Uni-
versity of Texas Dental School at San Antonio. He retired in 1992.
Senia is a diplomate of the American Board of Endodontics. He is
a former member of the Editorial Board and the Scientific Advisory
Panel of the Journal of Endodontics, an editorial advisor for the
Journal of Endodontic Practice and a consultant for the NASA
Space Program. He has lectured and published extensively and is
the co-inventor of the LightSpeedLSX™ root canal instrumenta-
tion and SimpliFill® obturation systems. You may contact Senia at
DrSteveSenia@aol.com.
10 I roots 1_ 2009
RO0109_1-52.indd 10
Larger LSX sizes, if advanced slowly (recom-
mended technique) to the same WL, will allow for
the development of an apical stop (matrix). Once
developed, the LSX would have to be pushed hard
to force it past the stop. Of course, demolishing
the constriction where the stop is located (the WL)
is not recommended. The apical stop confines our
fills to the WL and helps minimize the incidence of
overfills.
Notice the length marking rings on the shank of
the LSX (Figs. 3b, 3c). I can assure you that significant
time savings (and greater accuracy) is possible if you
use the rings in lieu of rubber endo stops. In fact,
Wildey recommends you have your assistant remove
the stops before bringing them chairside to force
yourself to make the transition.
Conclusion
In our subconscious minds, we are aware there is
a biologic tolerance to WL. Cases obturated a little
short (or a little long) are usually successful when
everything else is done correctly. WL need not be
perfect for a successful outcome (biologic toler-
ance), but the tolerance for an inaccurate WW is
not so generous. Avoid the temptation of indulging
in “aesthetodontic” contests. The endodontic com-
munity should agree to a WL that ranges 0.5 mm to
1.00 mm from the foramen (not apex) and move on
to more important issues.
I recommend all manufacturers use the term
electronic foramen locator (EFL) rather than apex
locator to describe these devices. EFL manufactur-
ers should eliminate ambiguous markings on their
devices and simply pinpoint only the foramen. Den-
tists would then “do the math,” thereby choosing a
termination point that is either 0.5 mm or 1.0 mm
short of that location. And finally, emphasis should
be placed on cleaning the main canal as well as pos-
sible (correct WW) close to the constriction/CDJ.
Doing so closes the door, prevents bacteria/toxins
from contaminating apical tissues and increases the
chances of endodontic success.
Smart Endodontics™ offers many helpful tips.
To learn more, please call Discus Dental at (800)
817-3636. Request the free CD showing what Smart
Endodontics is all about.
I wish to thank Steven S. Senia, BSIE, MBA, for his
valuable contribution to this article.
References
1. Glossary of Endodontic Terms. American Association of Endo-
dontists 2003, 7th Ed. Chicago, IL.
2. Yury Kuttler. Microscopic investigation of root apexes. JADA
1955; 50: 544–52.
3. Juan H, Gutierrez G, and Patricia Aguayo. Apical foraminal open-
ings in human teeth. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 1995; 79: 769–77.
4. Mandell et al. Principles and Practice of Infectious Diseases.
Churchill Livingstone, 5th Ed, 2000.
3/5/09 1:09:43 PM
RO0109_1-52.indd 11 3/5/09 1:09:50 PM
 I research_ obturation
The leakage resistance of
endodontic fiber obturator
Authors_Gregori M. Kurtzman & J. A. von Fraunhofer, U.S.A.
Fig. 1_After preparation and
obturation, a length of PVC-covered
copper wire was placed coronally
into each tooth in contact with the
obturation material and sealed in
place with sticky wax.
12 I roots 1_ 2009
RO0109_1-52.indd 12
F
Abstract
iber obturators have been introduced into
endodontics, but there are few reports of
their efficacy compared with standard
obturation materials. This study evalu-
ated the leakage resistance of fiber obtu-
rators compared with other obturation materials.
Sixty-four human single-rooted teeth, with 20
mm average working length, were used for the study.
Access was prepared coronally and patency confirmed
with a hand file. The canals were instrumented to
apical size ISO #40 with NaOCl irrigation, paper point
dried, rinsed with 17 percent EDTA solution, re-dried
and divided into eight groups of N=8. They were ob-
turated as follows: 1) InnoEndo fiber obturator with
InnoEndo adhesive and resin sealer. 2) InnoEndo fiber
obturator with a self-adhesive resin sealer. 3) Fibrefill
fiber obturator with Fibrefill adhesive and resin sealer.
4) Gutta-percha with Endorez resin sealer. 5) Endorez
cone with Endorez resin sealer. 6) Resilon cone with
Endorez resin sealer. 7) Gutta-percha with ZOE sealer.
8) Gutta-percha with AH26 sealer.
A PVC-covered copper wire was placed coronally
into each tooth in contact with the obturation mate-
rial and sealed in place with sticky wax. The exteriors
of the teeth and the wax-wire junctions were sealed
with three layers of nail varnish with care taken to en-
sure that the apices were patent. The teeth then were
immersed in 0.9 percent NaCl solution together with
a stainless steel counter electrode. A 20 V dc voltage
was connected between the stainless steel and each
tooth in turn, and current flow determined by voltage
drop across a standard resistor (100 Ω) in the circuit.
Current flow in the circuit was observed for 30 days
and ANOVA and Scheffé testing were used to compare
the leakage currents and identify any statistically sig-
nificant differences in the leakage behavior.
All specimens showed a progressive increase in
leakage with time. The specimen leakage fell into three
groups; the least leakage was found with obturations
1, 2, 3 and 5, the greatest leakage with obturations 4
and 8, with obturations 6 and 7 being intermediate.
The data indicate that fiber obturation and a new
cone/sealer system provide the best canal obturation
as evidenced by the leakage behavior.
Introduction
Leakage can be a hidden factor in endodontic
failure in that percolation at the margins of a res-
toration may be long standing before its effects are
apparent to the patient or the dentist. In fact, various
studies indicate that significant leakage may occur
within two days following exposure of teeth with
endodontically treated root canals to artificial and
natural saliva, leading to complete bacterial leakage.1
In vitro studies likewise indicate that dye leakage
can occur in as few as three days.1 It has also been
shown that gutta-percha does not offer an effective
barrier to crown-down leakage when exposed to the
oral environment due to poor bonding with various
sealers.1 Additional studies have indicated that gutta-
percha will allow bacterial leakage, although the use
of adhesive obturation materials can significantly
slow or stop coronal-apical bacterial migration.1
Nevertheless, despite its limitations, gutta-percha in
combination with various sealers traditionally have
3/5/09 11:38:12 AM
RO0109_1-52.indd 13 3/5/09 11:38:15 AM
 I research_ obturation
Fig. 2_The teeth were immersed in
0.9 percent NaCl solution together
with a stainless steel counter
electrode. A 20 V DC voltage was
connected between the stainless
steel and each tooth in turn, and
current flow was determined by
voltage drop across a standard
resistor (100 Ω) in the circuit.
Fig. 3_All specimens showed a
progressive increase in leakage
with time.
14 I roots 1_ 2009
RO0109_1-52.indd 14
been used for endodontic obturation.
In recent years, however, novel adhesive systems
have been developed in an attempt to improve leak-
age resistance. Fiber obturators were introduced to
the market several years ago as a method to address
the separate steps of obturation and post placement.
These unique obturators allow the practitioner to
obturate the canal and place a fiber post in a single
step, thus decreasing the possibility of apical leakage
compared to performance of these two stages when
performed at separate appointments. Ideally the best
time to completely seal the canal system and prevent
coronal leakage issues is at the time of canal obtura-
tion when a rubber dam is already in place.
The present study compared the leakage behavior
of the recently introduced InnoEndo fiber obtura-
tion system compared to that found with traditional
materials (gutta-percha used in combination with
both AH26 and zinc oxide eugenol [ZOE] sealants) and
the newer resin obturation materials. Leakage was
assessed using an electrochemical methodology,1,2,3
this approach being adopted because of its accuracy,
convenience and high correlation with traditional dye
leakage studies.1
Methods and materials
Sixty-four human single-rooted teeth, with 20
mm average working lengths, were used in the study.
Access was prepared coronally and patency confirmed
with a hand file. The canals were instrumented to
apical size ISO #40 with sodium hypochlorite (NaOCl)
irrigation, paper point dried, rinsed with 17 percent
EDTA solution and re-dried before being randomly
divided into eight groups of N=8.
The teeth were obturated as follows:
IN1: InnoEndo fiber obturator with InnoEndo ad-
hesive and resin sealer.
IN2: InnoEndo fiber obturator with a self-adhesive
resin sealer.
Fibrefil: Fibrefill fiber obturator with Fibrefill adhe-
sive and resin sealer.
GP-ER: Gutta-percha with Endorez resin sealer.
ER-ER: Endorez cone with Endorez resin sealer.
3/5/09 11:38:16 AM

ER-RES: Resilon cone with Endorez resin sealer.
GP-ZOE: Gutta-percha with ZOE sealer.
GP-AH26: Gutta-percha with AH26 sealer
(DENTSPLY DeTrey GmbH, Konstanz,
Germany).
After preparation and obturation, a length of PVC-
covered copper wire was placed coronally into each
tooth in contact with the obturation material and
sealed in place with sticky wax (Fig. 1). Thereafter, the
tooth/wax junction and all external surfaces of the
teeth were sealed and insulated with three layers of
nail varnish. Care was taken to ensure that the apices
of the teeth remained patent.
The teeth then were immersed in 0.9 percent NaCl
solution together with a stainless steel counter elec-
trode. A 20 V DC voltage was connected between the
stainless steel and each tooth in turn, and current flow
was determined by voltage drop across a standard
resistor (100 Ω) in the circuit (Fig. 2). Current flow in
the circuit was observed for 30 days. One way ANOVA
with post hoc Scheffé testing at an a priori = 0.05 was
used to compare the data and identify any statistically
significant differences in the leakage behavior.
Results
All specimens showed a progressive increase in
leakage over time (Fig. 3). Statistical analysis indicated
that there were no differences (p>0.05) between the
groups, primarily because of the large standard devia-
tions within the sets of data (Fig. 4). Nevertheless, the
trends in behavior indicated that specimen leakage fell
into three groups.
RO0109_1-52.indd 15
research_ obturation I
The greatest leakage was found in teeth obturated
with gutta-percha with Endorez resin sealer and those
obturated with gutta-percha and AH26 sealer — that
is, obturations 4 and 8.
The least leakage was found with teeth obturated
with an InnoEndo fiber obturator and InnoEndo ad-
hesive and resin sealer, an InnoEndo fiber obturator
with a self-adhesive resin sealer, an Endorez cone
with Endorez resin sealer and a Fibrefill fiber obturator
with Fibrefill adhesive and resin sealer — specifically,
obturations 1, 2, 3 and 5. Teeth obturated with gutta-
percha with Endorez resin sealer and those obturated
with a Resilon cone with Endorez resin sealer — obtu-
rations 6 and 7 — were intermediate in behavior.
Discussion
Methods for the study of leakage may be divided
into three methods — dye penetration, bacterial
penetration and electrophoresis. Both dye and bacte-
rial penetration methodology provide a qualitative
result. The results observed are either black or white,
the material leaks or it doesn’t leak. These methods
don’t inform us to what degree the material leaks. Dye
penetration studies will tell us there was dye leakage
along the canal, but to what degree this is clinically
significant has been debated as the dye molecule is
larger than the bacteria associated with endodontic
leakage seen clinically. Bacterial leakage studies were
an answer to that question. If the solution in the api-
cal chamber of a two-chamber model became turbid,
then it was an indication that bacteria penetrated the
canal system. But again, this is a qualitative result that
Fig. 4_Statistical analysis indicated
that there were no differences
(p>0.05) between the groups,
primarily because of the large
standard deviations within the sets
of data.
roots
1 _ 2009 I 15
3/5/09 11:38:16 AM
 I research_ obturation

does not inform us how leakage compares between
materials, only that it did leak and when leakage was
visible to the eye. Electrophoresis is currently the only
method testing leakage behavior that is able to provide
a quantitative result, allowing the determination how
much different materials leak. This methodology also
removes viewer bias as seen with the other meth-
odologies. Leakage is measured with an electronic
apparatus and is not dependant on the viewer saying
he or she could see a result (visible dye shown along
the canal’s length when the specimen was sectioned
or turbidity seen on the media solution).
Endodontic leakage studies invariably show a
scatter in leakage behavior, as evidenced by the large
standard deviations in the leakage data. All materials
will leak more over the initial period, and leakage be-
havior will plateau during the first 30 days then remain
fairly consistent thereafter. Nevertheless, the leakage
found in the present study for gutta-percha with
Endorez resin sealer obturation and teeth obturated
with gutta-percha and AH26 sealer was comparable,
if somewhat greater than, the findings of other leak-
age studies.1
The leakage found for fiber-obturated teeth was
similar to that observed with other modern obtura-
tion techniques and showed a significantly better
leakage resistance than gutta-percha with either ZOE
or AH26 sealers.
The findings of this limited in vitro study indicate
that the use of fiber obturators combined with newer
adhesives holds great promise for achieving consis-
tent leak-free root canal obturation.
References
1. Khayat A, Lee SJ, Torabinejad M. Human saliva penetration of
coronally unsealed obturated root canals. J Endod. (1993) 19(9):
458–461.
2. Swanson K, Madison S. An evaluation of coronal microleakage in
endodontically treated teeth. Part I. Time periods. J Endod (1987)
13(2): 56–59.
3. Cohen S, Burns R. Pathways to the Pulp. 8th edition, CV Mosby,
New York, 2001.
4. Britto LR, Grimaudo NJ, Vertucci FJ. Coronal microleakage as-
sessed by polymicrobial markers. J Contemp Dent Pract. (2003)
4(3):1–10.
5. Jacobson SM, von Fraunhofer JA. The investigation of microleak-
age in root canal therapy. Oral Surg Oral Med Oral Path (1976)
42: 817–823.
6. Mattison GD, von Fraunhofer JA. Electrochemical microleakage
study of endodontic sealer/cements. Oral Surg Oral Med Oral Path
(1983) 55: 402–407.
7. von Fraunhofer JA, Fagundes DK, McDonald NJ, Dumsha TC. The
effect of root canal preparation on microleakage within endo-
dontically treated teeth: an in vitro study. Int Endodont J (2000)
33: 355–360.
8. von Fraunhofer JA, Adachi EI, Barnes DM, Romberg E. Effect of
tooth preparation on microleakage behavior. Oper Dent (2000)
25: 526–533.
9. von Fraunhofer JA, Klotz DA, Jones OJ. Microleakage within endo-
dontically treated teeth using a simplified root canal preparation
technique: an in vitro study. Gen Dent (2005) 53: 439–443.

_About the authors roots

Gregori M. Kurtzman, DDS, MAGD, DICOI
Dr. Gregori M. Kurtzman is in private general practice in Silver Spring, Md., and is a former assist-
ant clinical professor at the University of Maryland School, Baltimore College of Dental Surgery,
Department of Endodontics, Prosthetics and Operative Dentistry. He has lectured both nationally
and internationally on the topics of restorative dentistry, endodontics and dental implant surgery
and prosthetics. He has published over 130 articles in peer-reviewed publications on numerous
dental topics. He is a consultant and evaluator for several dental companies. He has earned fel-
lowships in the Academy of General Dentistry, the International Congress of Oral Implantologists,
the Pierre Fauchard Academy and the American College of Dentists and masterships in The
Academy of General Dentistry and the Implant Prosthetic Section of the International Congress of
Oral Implantologists. He can be contacted at dr_kurtzman@maryland-implants.com.

J. Anthony von Fraunhofer

Dr. J. Anthony von Fraunhofer is professor emeritus at the University of Maryland School of
Dentistry. He has a BSc in chemistry, an MSc and PhD in metallurgy with Chartered Scientist,
Chartered Chemist and Chartered Engineer designations from the United Kingdom Science
Council. He holds fellowships in the Academy of Dental Materials, ASM International, the Institute
of Corrosion and the Royal Society of Chemistry. After several years of industrial research and
development, von Fraunhofer joined the Institute of Dental Surgery, University of London and
eventually chaired the Department of Biomaterials Science. He was recruited to the School of
Dentistry, University of Louisville in 1978 and moved to the School of Dentistry, University of
Maryland in 1994. von Fraunhofer has mentored 14 PhD and 120 MS degree candidates, and
he has written over 400 scientific papers, 11 books and contributed chapters to 12 monographs.
He has made over 140 research presentations at national/international meetings and lectured
and presented courses in the United States, England, Continental Europe, North Africa and the
Middle East. His fields of interest include biomechanical properties of materials; dental cutting;
wound closure devices and wound healing; degradation, wear and corrosion of materials in the
biosystem and in industry. He can be contacted at javf@comcast.net.

16 I roots 1_ 2009

RO0109_1-52.indd 16 3/5/09 11:38:17 AM

W&H_UK_EndodonticPractice-08_A4+.qxp 13.02.2008 18:55 Seite 1

Think Endo cordless!

No cord. Full power. Entran sets new standards in the area of cordless endodontics and
combines the highest level of ergonomics with consistent W&H quality. For root canal
preparation, there are a number of features at your disposal e.g. torque control, automatic
direction change and 5 preset torque levels for NiTi files. Simple to operate, so you can
concentrate on the treatment. With Entran you can enjoy complete freedom of movement
inside the entire mouth - even in the most inaccessible posterior molar area.

wh.com
Endodontics. Cordless!
 I trends_K3 rotary nickel titanium instrumentation
K3 rotary nickel titanium
instrumentation: Blending
safety and efficiency
Author_ Gary Glassman, Canada
Fig. 1_The cross section
of the K3 RNT.
Fig. 2_K3 in longitudinal
cross section.
18 I roots 1_ 2009
RO0109_1-52.indd 18
A
mong the options available, since the
introduction of rotary nickel titanium
(RNT) instrumentation, choosing be-
tween many existing RNT systems
has, largely, been a decision between
safety and efficiency. Some instruments cut well
but tended to transport canals. Others created less
transportation and are relatively safer, but also less
effective at shaping dentin.
Complicating matters, there is no literature-based
proven superiority of one RNT file system over an-
other available at this time. As a result, selection of
one RNT file system over another has been primarily
empirical and, for many, been based more on tactile
feel and ease of cone fit after preparation than any
measurable scientific parameters. Each file has its
own learning curve, some steeper than others. Mak-
ing decisions even more complex, various file systems
have been introduced with different technique and
tactile recommendations. In essence, each RNT file is
unique in many ways based on a number of factors,
including design, use recommendations, etc. For
example, there are variations among some systems
(among many things) in the:
a. Number of recommended uses.
b. Type of tactile insertion (pecking motion, single
insertion, multiple insertion, etc.)
c. Method of use, i.e., crown down method, step
back method, and/or using a hybrid technique
employing both concepts.
d. Recommended rotational speeds. Recom-
mended rotational speeds vary from approxi-
mately 300 to 2,000 rpm.
Coincident to the above, there is debate in the
endodontic community as to the ideal master apical
file (MAF) size, a debate that has a direct relationship
to the capabilities and limitations of the given RNT
file system. Some file systems may not be flexible
enough to get around severe curvatures in larger
tapers. With some systems, the MAF possible may
be limited by the available file sizes. For example, if a
file system is available to only a #40 tip size (or some
similar diameter) that is the limiting factor imposed
onto the clinician, irrespective of what the literature
might suggest as optimal.
RNT file systems also differ based on the following
attributes (among others):
1. Cross-sectional design and degree of sym-
metry.
2. Presence or absence of radial lands.
3. Presence or absence of a positive, neutral or
negative cutting and rake angle.
4. Whether the file was ground, stamped, or
manufactured via a different method.
5. Flute width and flute depth.
6. Helical angle.
7. Presence or absence of reliefs behind the radial
lands.
8. Electro polishing.
9. Active versus non-cutting tips.
3/5/09 11:39:58 AM
 trends_K3 rotary nickel titanium instrumentation I

10.Fixed tapered, non-tapered, or viable tapers.

11. Length of the flutes on the file in longitudinal
section.
It is noteworthy in comparing RNT file designs
that the larger the diameter of the file, the greater
the file’s resistance to torsional forces. Alternatively,
larger files resist cyclic fatigue less well. The smaller
the diameter of the file, the greater the resistance of
the file to cyclic fatigue, and the resistance to torsion
is diminished. In essence, one aspect of determining
safety in choosing a RNT system is also a balance of
choosing the correct diameter tip size and taper of
the RNT file for the particular degree of curvature
to optimally resist the forces of torsion and cyclic
fatigue.
With the above introduction, how then is the cli-
nician to make a selection of a system that cuts well,
resists breakage and does not transport canals? I have
found that the K3 RNT system from SybronEndo, Or-
ange, Calif., is flexible, durable and fracture-resistant,
Fig. 3
combining these features with excellent tactile con-
trol. In short, K3 bridges the gap between safety and
efficiency.
Due to the scope of this paper, it is not possible to
compare and contrast K3 in all of its design charac-
teristics to all of the other brands available in North
America. This notwithstanding, the primary design
features of K3 are described here.
1) Cross-sectional design and degree of symmetry.
K3 is asymmetrical in all its cross-sectional design
characteristics. The more symmetrical the file, the
more likely the file will tend to “screw in” to the ca-
nal. The intention behind this asymmetry is that the
clinician must power the file and not allow the file to
“screw in.” The asymmetry gives the clinician greater
tactile control over the file during insertion. Asymme-
try creates one of the hallmarks of K3, there is little no
tendency for “screw in.” The clinician powers the file
moving apically and does not have to be concerned
that the file will grab in the canal and propel itself
apically (Figs. 1, 2).
2) Presence or absence of radial lands. Radial lands
are placed on the file to center the file, minimize
transportation and to provide metal mass behind the
cutting edge of the flute as it rotates.
3) Presence or absence of a positive cutting angle.
K3 is the only file in North America that has a posi-
tive cutting angle on the flutes. Other RNT systems
in North America are designed to cut by a scraping
motion that requires the advancing edge of the file to
remove dentin passively.
4) Whether the file was ground, stamped or con-
structed via a different method. The grinding of nickel
titanium creates microcracks on the surface of the
nickel titanium wire it is made from. The microcracks
can propagate if the file is subjected to cyclic fatigue
forces or to excess torsion. Lightspeed (Discus Dental, Figs. 3a–3c_The K3 rotary nickel titanium file system (SybronEndo, Orange, Calif.) —
Culver City, Calif.) makes the only non-ground and the Procedure Pack, the G-Pack and the VTVT Pack

roots
1 _ 2009 I 19

RO0109_1-52.indd 19 3/5/09 11:39:59 AM

 I trends_K3 rotary nickel titanium instrumentation
Fig. 4_The new and improved M4
handpiece (SybronEndo, Orange,
Calif.)
non-tapered RNT file at this time, which is stamped.
All other RNT files are ground with the limitations that
microcracks are created. K3 overcomes many of the
limitations imposed by these microcracks due to the
design characteristics of the file (lack of symmetry,
radial lands, non-cutting tip, etc.)
5) Flute width and flute depth. Flute width and
depth increases for K3 as the clinician moves away
from the tip of the file. Such increasing width and
depth provides space for chips derived from cutting.
Such channeling of debris reduces torsion.
6) Helical angle. K3 has a greater number of flutes
at the distal 8 mm of the file that makes the apical
portion of the file as flexible as possible and resistant
to fracture. This also provides more cutting flutes at
the portion of the file where they are needed most
during function.
7) Presence or absence of reliefs behind the radial
lands. Two of the three radial lands of K3 are relieved
to reduce the friction of the file against the canal
walls and to allow more room for chip debris as it is
formed.
8) Electro polishing. K3 is not electropolished.
While advocated by some, electropolishing can dull
the cutting edges of the file as well as change the
surface structure of the metal to varying degrees.
9) Active versus non-cutting tips. K3 has a non-
cutting tip. Any RNT file can fracture when used
inappropriately. Empirically, a lack of cutting at the
tip of K3 is borne out by the fact that although rare,
when K3 might fracture, it usually does not fracture
3–4 mm at the tip.
10) Fixed tapered, non-tapered, or viable tapers.
K3 is a fixed tapered instrument. This means that the
final prepared taper and tip size is inherently built
into the file. This is significant because some other file
designs require that the clinician blend several (po-
tentially many) RNT files to create a continuous taper
from the orifice to the apex. With K3, if a 0.06 #30 or
35 file is taken to the true working length (TWL), the
preparation is final and ready to obturate for an aver-
age molar tooth (unless the clinician desires to create
larger apical diameters) and blending with additional
RNT files is not necessary to create the final ideal
prepared canal shape.
K3 is available in six tapers: 0.12, 0.10, 0.08, 0.06,
0.04, and 0.02. The 0.12, 0.10, and 0.08 are available in
20 I roots 1_ 2009
RO0109_1-52.indd 20
a 25-tip size and are generally used as orifice openers.
The 0.02 K3 is available in tip sizes of #15 to 45. The
0.04 is available from #15 to 60. The 0.06 K3 is avail-
able from 15 to 60. K3 is packed into three different
pack configurations, the Procedure Pack, the G Pack
and the VTVT Pack.
The Procedure Pack contains either a 0.06 or 0.04
taper:
0.10 .25 tip 17 mm
0.08 .25 tip 17 mm
0.06 (.04) 40 tip 21 or 25 mm
0.06 (.04) 35 tip 21 or 25 mm
0.06 (.04) 30 tip 21 or 25 mm
0.06 (.04) 25 tip 21 or 25 mm
The G Pack contains:
0.12 25 tip 17 mm
0.10 25 tip 21 or 25 mm
0.08 25 tip 21 or 25 mm
0.06 25 tip 21 or 25 mm
0.04 25 tip 21 or 25 mm
0.02 25 tip 21 or 25 mm
The VTVT (variable taper, variable tip) Pack contains:
0.10 25 tip 21 or 25 mm
0.08 25 tip 21 or 25 mm
0.06 35 tip 21 or 25 mm
0.04 30 tip 21 or 25 mm
0.06 25 tip 21 or 25 mm
0.04 20 tip 21 or 25 mm
There is no inherent or functional superiority
of any one given pack configuration over another.
Choosing any particular pack configuration over any
other is a matter of clinician preference. The above
statement notwithstanding, common empirical rea-
sons for favoring one pack over another are listed here
in discussion of the configurations.
1) The Procedure Pack is generally used in a
straight crown down method, in essence using the
files from larger tapers to smaller and from larger tip
sizes to smaller. Because of the diminishing tip sizes,
each K3 file should and does advance slightly api-
cally relative to its precursor as it is inserted (which is
inherently crown down). For straight canals and mild
to moderate curvatures, as would be treated by most
3/5/09 11:39:59 AM
RO0109_1-52.indd 21 3/5/09 11:40:05 AM
 I trends_K3 rotary nickel titanium instrumentation
Figs. 5a–7b_Clinical cases treated
with the K3 as described.
22 I roots 1_ 2009
RO0109_1-52.indd 22
general practitioners, this is an excellent choice for a
single pack configuration (Fig. 3a).
2) The G Pack is preferred by some because the
files may progress more rapidly toward the apex than
with some of the other configurations. Diminishing
taper (as opposed to diminishing tip sizes) allows the
K3 file to move apically with efficiency. Some believe,
with various tapers, that this pack can treat a slightly
greater range of anatomy than with the Procedure
Pack (Fig. 3b).
3) The VTVT Pack is favored by some because with
the variation in taper, with progressive insertions,
torsional stresses on subsequent files decrease due
to minimized engagement relative to a reinsertion of
the taper. Many endodontists favor the VTVT Pack for
this reason (Fig. 3c).
4) K3 is used either crown down or step back. When
using K3 crown down, the file is used from larger
tapers to smaller or from larger tip sizes to smaller.
Moving down the root, the given K3 files are advanced
until the clinician reaches the estimated working
length (EWL), and then the TWL is taken with an elec-
tronic apex locator and the preparation finalized.
If K3 is used step back, the clinician uses smaller
K3 files initially in an attempt to reach the EWL and
establish TWL as rapidly as possible with an electronic
apex locator. For example, if the clinician were to
use a VTVT step back and the 0.04 0.20 K3 reached
the EWL after the orifices were shaped, the clinician
would then advance up the canal from the smaller
tapers and tip sizes to larger to the desired final tip
size and taper, i.e., a reverse order of the crown down
technique.
In any event, it is vital that the clinician use the
correct tactile control of the K3 (as with any RNT file)
moving either crown down or step back to minimize
over engagement and uneccessary fracture risk.
Tactile control
1) Passive gentle insertion. If the file resists ad-
vancement, undue pressure is not put on the file to
move apically.
2) Minimal engagement to avoid taper lock. Ide-
ally, each K3 insertion will cut 1–2 mm of dentin and
after irrigation and recapitulation, the next K3 in the
sequence is inserted.
3) Creation of a glide with hand files. Manual pre-
flaring of a canal with hand files give the K3 (and all
RNT files) a path to track to avoid debris blockage and
locking of the tip in a previously unexplored portion
of the canal.
4) K3 is never left stationary in the canal. The file is
either inserted or withdrawn, but never left rotating
at the same level.
5) K3 is inserted in 2–3 seconds to resistance and
then withdrawn, the file is not arbitrarily pushed api-
cally if it does not want to progress. The motion is con-
tinuous and controlled and engagement of the flutes
of the file should be minimized to the greatest extent
possible, ideally to 1–2 mm per insertion. The same K3
is never reinserted repeatedly to the same level in the
canal. There is no value in such a motion.
6) The M4 Safety handpiece is an excellent adjunct
to the K3. The M4 is a reciprocating handpiece attach-
ment that can take hand K-file, reamer, or Hedström
files (among others) and move the files alternatively
30 degrees clockwise and 30 degrees counterclock-
wise. The M4 fits onto any E type attachment of an
electric motor. The M4 saves time, hand fatigue and
makes predictability a hallmark of initial hand file
negation of canals. For example, if a MB2 canal is
narrow, has multiplanar curvature and is difficult to
initially negotiate to the EWL, use of the M4 can make
enlargement of this space simple and predictable to
the size needed for a glide path. In clinical practice,
the #6 hand K file is placed to the EWL, which clinically
can often be felt as a pop as the hand K file exits the
apical foramen just beyond the minor constriction.
Once the #6 drops to length, the file is left in the tooth
and the M4 is placed onto the hand file under the
rubber dam and in the tooth. With a full depression
of the foot pedal and the motor set on 900 rpm and
the 18:1 setting, the M4 is activated and the file will
reciprocate clockwise and counterclockwise as noted
3/5/09 11:40:05 AM

above. With amplitude of 1-3 mm for approximately
15 seconds, the file is moved vertically and apically
with a gentle and passive motion. Usually, in ap-
proximately this period the initially restrained #6 is
able to move freely in the canal. The orifice of the
canal is irrigated and the canal recapitulated. Then a
#8 is placed and the process repeated, a #10 is then
used, etc. until the desired initial diameter is present.
If the ideal initial negotiating file is a #8 or #10 based
on the initial anatomy of the canals, these files can
certainly be used first instead of the #6. It is difficult
to fracture a file with an M4; the technique is very safe
and highly effective (Fig. 4).
Expanded K3 functionality
1) 0.02 tapered K3 files offer a powerful arsenal
of options, especially in negotiating several apical
third curvatures. Clinically, if, for example, a canal
has a glide path created with the M4, the 0.02 #15 K3
can be brought into the canal to the EWL or TWL. The
initial enlargement of the canal path that is made in
this manner with the 0.02 #15 can be enlarged to a
#20 with the 0.02 #20 K3. This creates an excellent
pathway for the subsequent sequence of K3 instru-
ments that will be used, irrespective of the pack con-
figuration or whether the sequence is crown down or
step back in nature.
2) K3 can create larger apical diameters as desired.
Since the 0.04 tapers are available to a #60, the 0.06
is available to a #60, and the 0.02 is viable to a #45,
K3 can be used to prepare apical diameters of virtu-
ally any diameter short of an open apex (i.e., 60 and
above). This flexibility is not a common feature of the
RNT systems available on the market. The value of this
functionality cannot be overstated as the endodontic
literature is very clear that larger final prepared api-
cal diameters create cleaner canals relative to smaller
ones.
3) K3 can be rotated at a wide variety of speeds
depending on the wishes of the clinician. SybronEndo
recommends that K3 be rotated at approximately 350
rpm, but some have advocated its use at up to 900 rpm
and faster for removal of gutta-percha in retreatment
(up to 1,500 rpm). What is clear is that if the tactile
control over K3 is correct, the files can be rotated at
higher speeds than 350 and done so very efficiently.
K3 FAQ
Can you run K3 with any type of electric motor?
Does K3 have to be used with torque control?
K3 can be used with any brand of electric motor,
corded or cordless. K3 can be used with torque con-
trol, but it does not have to be. Many endodontists use
K3 (and other RNT files) with the torque control off.
Can K3 files be used in coordination with other RNT
file brands?
While K3 is a complete system, K3 can be combined
RO0109_1-52.indd 23
trends_K3 rotary nickel titanium instrumentation I
with any RNT brand desired.
What is the most common sequence of K3 use?
Common sequences of K3 include:
a. crown down from larger tapers to smaller and
from larger tip sizes to smaller, if the tactile control
is correct.
b. Step back, using K3 from smaller to larger
tapers.
Literally, for both of these techniques, the K3 files
can be placed from the pack configurations into the
sponge in the same order they were packaged and
the files are used in this order, crown down (primarily
larger to smaller) or step back (primarily smaller to
larger) as described here.
In both of these techniques, initial negotiation and
creation of a glide path with hand files is essential to
precede the K3 in the given portion of the canal being
enlarged.
Is K3 stiff?
K3 is not inherently stiff. The “feel” of K3 in one’s
hand has no translation to its clinical function. Clini-
cally, if K3 is used appropriately (correct rotational
speed, method of insertion, engagement, etc.) it is
more than flexible enough to handle even the most
challenging curvatures.
How many times can I use a K3 file?
Individual preferences vary. I generally use my
K3 from 3–5 molar teeth. If there are any wear
marks, stretches, kinks, bends, etc., it is discarded im-
mediately. Smaller taper and tip sized K3s might be
discarded after a single use (0.02 #15 and #20 files)
and the larger tapers, a 0.04 and 0.06 above a #20 can
be used more often.
Can I match my K3 preparation with gutta- percha
points?
Matched K3 gutta-percha is available. The final
prepared taper and tip size of the K3 file is matched
by a gutta-percha point with little if any adjustment
of the cone being necessary.
What do I do if I can’t get a hand file beyond some
level in the canal? Do I use K3 to the level of the block-
age and then fill at that level? Will this reduce my
success?
Part of the answer depends on whether the area
of blockage could once be bypassed or not. If the
blockage could never be bypassed from the start of
treatment, it may or may not be negotiable. If the
level of the canal that is now impassable was once
negotiable, the blockage has obviously been created
by the clinician and the chances improve somewhat
that bypassing can be achieved.
If referral is an option, such an event is often an
indication for referral, especially, if the given block-
roots
1
_ 2009 I 23
3/5/09 11:40:05 AM
 I trends_K3 rotary nickel titanium instrumentation
age was not present earlier in treatment. Precurving
hand files for use in such situations is essential. Such
bending (a small J bend at the tip of the file) allows
the hand file to negotiate the canal more easily, espe-
cially a curved canal. The EndoBender (SybronEndo,
Orange, Calif.) is an excellent instrument for this pur-
pose. In a canal filled with irrigant and a precurved
hand file, the clinician should make every effort to
bypass the blockage to regain canal patency. This
effort to bypass the blockage may take many hand
files and repeated insertions from different orienta-
tions to determine if there is any negotatible canal
space. There is value, of course, in taking a radiograph
to see if visible canal transportation has occurred
or perhaps a separated file is blocking the canal,
amongst other possible sources of obstruction. If
the canal can be subsequently negotiated by hand
and the blockage bypassed, the glide path should be
reestablished (an M4 would be very helpful for such
a task) and the smaller tapers and tip sizes of K3 used
first to create a minimal diameter. Subsequently, the
final apical preparation of the desired taper and tip
size can be created.
How do I know when to stop the preparation?
When am I done with K3?
Globally, most clinicians will finish their apical
preparation to approximately a #25 or 30, but the
rationale and methodology for creating master apical
diameters varies widely. There is strong evidence in the
endodontic literature that larger apical preparations
result in cleaner canals. One method to determine
what the ideal master apical diameter might be is to
gauge the canal, i.e., determine the initial diameter
of the minor constriction of the apical foramen. To
gauge the apex, the clinician can determine the hand
file that meets resistance at the minor constriction for
the apical foramen and from this measurement make
a determination of the ideal final prepared diameter.
For example, if a #30 hand K file meets resistance at
the minor constriction and will not pass with mild
pressure, the master apical preparation can be taken
to a 45. While this is certainly not an exact science, this
allows the canal to dictate the final preparation rather
than imposing onto the canal an arbitrary MAF.
Where should I stop the preparation exactly and
how is this influenced by K3?
There is no universal agreement about the ideal
filling point of obturation. Rationales and method-
ologies vary as to the ideal filling point. In practical
clinical terms, the minor constriction of the apical
foramen is the natural termination point for instru-
mentation, irrigation and obturation. The position
of the narrowest diameter of the minor constriction
is accurately determined by the use of an electronic
apex locator and often confirmed with a bleeding
point determination. Some would argue that the
24 I roots 1_ 2009
RO0109_1-52.indd 24
ideal position for obturation might be short of the
minor constriction and others make a distinction be-
tween vital and necrotic cases, with vital cases filled to
just short of the minor constriction and necrotic cases
obturated to the minor constriction. It is beyond the
scope of this paper to comprehensively review these
concepts. With tactile control, the use of a bleeding
point determination, the electronic apex locator and
possibly radiographic information, the position of
the minor constriction of the apical foramen can be
determined very accurately. With K3’s functionality,
preparations can be made with enhanced MAFs to the
minor constriction as needed.
What do I do if I want to advance the K3 file in my
sequence and it does not want to advance?
As with all RNT files, the K3 should never be forced
to move apically. If, for example, using a G Pack, the
0.08 orifice opener has been used to the point of the
first curvature and the 0.06 does not want to progress
passively beyond this first curvature, the clinician
would go to the 0.04 25. This should progress slightly
beyond the initial root curvature. If the 0.04 will not
allow initial engagement beyond the desired level,
the clinician can then move to the 0.02 tapered K3 25,
which should easily advance beyond all but the most
severe curvatures.
Alternatively, the clinician can create more taper
above the point of resistance (by using the 0.12, 0.10
and 0.08 tapered 25 K3) and then attempt to place the
.06 again into the root beyond the curvature.
How are irrigation and patency maintenance in-
serted into the K3 sequence?
Irrigation and maintenance of patency with hand
files (0.08 file size, slightly past the apical constric-
tion) are ideally performed after every K3 insertion.
Frequent irrigation and patency maintence keeps the
canal open and negotiable, thereby preventing apical
debris blockages and minimizes the possibility for
iatrogenic events. The importance of such irrigation
and patency maintenance cannot be overstated in the
context of prevention of iatrongic events of all types
(separated instruments, ledging, perforation, etc.).
Blockages can easily lead to deflection of instruments
away from the true canal path and cause iatrogenic
issues.
Enlargement should take place with a sequence of
insertion, irrigation and patency maintenance. Ide-
ally, and especially in difficult curvatures and calci-
fied canals, this irrigation and patency maintenance
should optimally take place after every K3 insertion.
How do I know when it is time to throw a K3 file
away?
If a kink, bend or deformation should appear with
K3, it should be immediately discarded. Torsional
stresses and cyclic fatigue stresses on files are cu-
3/5/09 11:40:05 AM
 trends_K3 rotary nickel titanium instrumentation I

mulative; when in doubt, the file should always be
discarded.
Can I use K3 to remove gutta-percha, pastes and
warm carrier based products?
Yes. Usually, such procedures are performed by
endodontists and done so at enhanced rotational
speeds, from 900 rpm to 1,500 rpm. Use of such
enhanced speeds requires experience, caution and
clinical judgment.
All RNT systems are optimized by the following
strategies.
1) Use of a surgical operating microscope (SOM)
(Global Surgical, St. Louis, MO, USA). A clinician can
never have enough lighting, magnification and visu-
alization in endodontics.
2) Manual preflaring of the canal to create a mini-
mum #15 sized glide path before RNT insertion. In
essence, before a K3 is placed into any canal, the canal
has an initial diameter of at least a #15 hand file.
3) Lubrication is essential before insertion of a RNT
file. In vital cases with a great deal of pulp, a viscous
EDTA gel (File Eze, Ultradent, South Jordan, Utah) is
appropriate until at least the greatest bulk of pulp
is removed from the canals. After removal of the
majority of pulp and the chamber is cleaned, sodium
hypochlorite can be used as the primary irrigant in
vital cases. In non-vital cases and retreatment, gener-
ally chlorhexidine is more commonly used.
4) Straight-line access is ideal. All files, hand and
RNTs, should not deflect on insertion into the canals.
5) The clinician must appreciate at all stages of the
enlargement process the EWL (and TWL once known)
to correlate the position of the RNT file tip to minimize
the chances for apical transportation via inadvertent
insertion through the minor constriction.
6) The RNT files should be lined up on the sponge
in the expected order of use or, alternatively, the
clinician may place each RNT into a handpiece at-
tachment. Exchanging the attachments into the
handpiece (corded or cordless) is far more efficient
than replacing each single RNT into the attachment.
While there is an initial investment in attachments,
these multiple attachments can save valuable time
between instrument switches.
7) Preoperatively the tooth should be evaluated
for all foreseeable risks of possible iatrogenic events.
Coincident to this evaluation, the clinician should de-
termine what the anticipated final taper and tip size
of the preparation might be. The final prepared taper
is generally a 0.06 taper throughout the length of
the preparation for most of the teeth treated in both
specialty and general practice. Thus, it is certainly
possible that the final prepared taper and anticipated
tip size can change after the tooth is opened. It must
be remembered that the tooth dictates the shape of
the final preparation. The final and taper and tip size
are not dictated onto the tooth by the clinician (Figs.
5a–7b).
A comprehensive view of the K3 RNT system has
been discussed to allow the clinician to utilize the
instrument in clinical practice. Emphasis has been
placed on:
1) The instrument is asymmetrical in all of its
design characteristics and and, as a result, has little if
any tendency to “screw in” as do many designs that
are more symmetrical.
2) As with all RNT files, a glide path is advised. The
M4 safety handpiece is a very useful adjunct to K3
technique in creating the glide path.
3) K3 can be used crown down or step back. In
either event, insertion of the file is gentle, passive and
should minimize engagement of dentin.
4) K3 is a complete system from which enhanced
master apical diameters can be created for a wide
range of clinical anatomies.

_About the author roots

Gary Glassman, DDS, FRCD(C)

Gary D. Glassman graduated from the University of Toronto, Faculty of Dentistry in
1984 and was awarded the James B. Willmott Scholarship, the Mosby Scholar-
ship and the George Hare Endodontic Scholarship for proficiency in endodontics.
A graduate of the Endodontology Program at Temple University in 1987, he
received the Louis I. Grossman Study Club Award for academic and clinical
proficiency in endodontics. The author of numerous publications, Glassman is on
staff at the University of Toronto, Faculty of Dentistry in the graduate department
of endodontics. A renowned international lecturer on endodontics, Glassman has
presented at major dental conferences around the world including the annual
conference for the European Society of Endodontology, the Canadian Dental
Association, the Ontario Dental Association, the California Dental Association,
the Texas Dental Association and the Irish Dental Association. He can be reached
through his Web site, www.rootcanals.ca.

roots
1
_ 2009 I 25

RO0109_1-52.indd 25 3/5/09 11:40:06 AM

 I trends_ taper and apex locator
Answering two frequently
asked clinical endodontic
questions: How much taper?
How do I troubleshoot my
apex locator?
Author_ Richard Mounce, U.S.A.
G
lobally, the endodontic questions asked
by general practitioners are very com-
mon. Two of the most frequent are ad-
dressed here. While the specific instru-
ments used to accomplish a root canal may vary, the
principles advised in the answers are universal. At
the heart of each of the answers is a goal to remove
bacteria to the greatest extent possible from the root
canal system, obturate the canal system in three
dimensions and create a post endodontic coronal
seal as soon as possible after treatment. These goals
are consistent with the goals of endodontic canal
enlargement, which are to: three-dimensionally
Fig. 1_The Twisted File (SybronEndo,
Orange, Calif.)
26 I roots 1_ 2009
RO0109_1-52.indd 26
clean and shape the canal space from the orifice to
the minor constriction (MC) of the apical foramen
and do so in a way that minimizes or eliminates the
risk of subsequent vertical fracture. Inherent to safe
and efficient canal enlargement is adherence to the
primary principles of canal preparation (maintain-
ing the MC in its original position and size, keeping
the canal in its original position and only enlarging
it in the shape of a tapered funnel with narrowing
cross-sectional diameters). Secondary goals of
canal preparation are to prepare a canal that has a
taper and size to optimize irrigation and obturation.
With these goals as a foundation, the following two
clinical questions are answered.
Question 1: How do I know what taper to
prepare for a given canal? Does it matter,
particularly in the apical third?
This question is clinically more relevant than ever
with the introduction of the Twisted File (SybronEndo,
Orange, Calif). The TF, due to its manufacture, in-
cludes a proprietary process that never cuts across
the grain structure of the metal, which allows a flex-
ible and highly efficient enlargement of the canal
to the MC and does so with greater flexibility and
fracture resistance than ever before. The TF is avail-
able in five tapers — 0.12, 0.10, 0.08, 0.06 and 0.04.
Depending on the anatomy encountered, the TF can
prepare a taper of 0.12, 0.10 and 0.08 into the apical
3/5/09 1:16:48 PM
 trends_ taper and apex locator I

third, far larger than that possible with ground rotary

nickel titanium (RNT) instruments (Fig. 1).

Several important points should be made with

regard to choosing a taper.
1) Greater taper in preparations removes more
tooth structure than less taper, and a greater taper
carries with it more risk of strip perforation and
long-term risk of vertical root fracture, especially if
a root form is enlarged more than absolutely neces-
sary (Fig. 2).
2) Generally, greater taper is used in less complex Fig. 2_Excessive taper that led to a
root canal forms. Less taper is used in more complex strip perforation in this lower molar.
root forms.
3) Greater taper taken apically increases the
chances for cyclic fatigue failure of instruments.
In other words, more metal mass in files gives RNT
instruments greater resistance to torsional stresses
and yet reduces their ability to withstand flexural
failure — i.e., failure from cyclic fatigue. With regard to
taking instruments of greater taper further apically, it
should be remembered that such instruments would
have fewer revolutions to failure due to cyclic fatigue,
relative to other smaller, less tapered instruments.
4) Use of greater taper prepares larger apical
diameters further apically in addition to the taper
of the preparation. For example, with a 0.10 tapered Fig. 3_Clinical case performed with
instrument, such as the 0.10 TF, which is a 25 at its a single TF instrument.
tip, 1 mm back from the tip, it is a 35 and 2 mm back
it is a 45. Such a rapid increase in size has ramifica-
tions aside from the risk of strip perforation in that if
the instrument is taken beyond the MC it can rapidly
transport the MC. Such an event is consistent with
apical bleeding, challenges in cone fit, extrusion of
sealer and irrigants, etc. Knowing the exact position
of the MC as well as having precise control over the
position of the RNT file tip at all times are consistent
with the most efficient possible use of greater tapers.
The converse is also true.
5) Greater tapers, used apically, such as that
which are possible with the TF, ideally require that
the clinician have an excellent glide path in which to Fig. 4_Clinical case performed with
place the RNT. The use of a reciprocating handpiece, two TF instruments.
such as the M4 (SybronEndo, Orange, Calif.), allows
efficient and rapid creation of a glide path relative to rily as orifice openers and are generally not used to
its creation by hand. the MC. 0.12 RNT files are generally used only at the
Generally, but with exceptions (for example, orifice and not into the middle third. Whether a 0.12
variably tapered RNT file systems), most RNT files are RNT should be used in the coronal third or just beyond
manufactured in 0.12, 0.10, 0.08, 0.06 and 0.04 ta- the orifice is entirely case dependent relative to the
pers. Except for the TF and the LightSpeed Instrument existing anatomy, width of dentin at the furcation
that is stamped (Discus Dental, Culver City, Calif.), all and the RNT instrument considered. In any event,
RNT instruments are ground from a blank of nickel 0.12 RNT files should not be used indiscriminately.
titanium wire. Grinding produces microcracks that Quite the opposite, of the RNT instruments available,
can act as the focus points for fracture. regardless of the brand, these files should be used
with the utmost caution because of the aforemen-
The use of various tapers in different anatomies is tioned risk of stripping and vertical fracture.
discussed below. It is very rare that a 0.12-tapered RNT would or
A) 0.12 tapered RNT instruments are used prima- should be taken to the MC. However, there are situ-

roots
1 _ 2009 I 27

RO0109_1-52.indd 27 3/5/09 1:16:48 PM

 I trends_ taper and apex locator
Fig. 5_Accurate location of the minor
constriction of the apical foramen.
Fig. 6_Lack of accurate working
length determination that led to
apical transportation and iatrogenic
outcome.
Fig. 7_The Elements Diagnostic Unit
(SybronEndo, Orange, Calif.)
28 I roots 1_ 2009
RO0109_1-52.indd 28
ations where this may be possible and advisable. For
example, the TF might be able to be taken into the
apical third of some wide-open palatal roots and ca-
nines due to its flexibility and cutting ability. As men-
tioned though, this would be uncommon. For this to
be possible, an excellent glide path would be needed
to the MC, irrigation and recapitulation would be
mandatory after every file insertion and the canal
could not have any apical abrupt curvature — i.e.,
it must be relatively straight and uncomplicated to
the MC. The clinician would know if this was the case
through careful evaluation of the initial radiographs
as well as the tactile negotiation of the canal by hand
in the early stages of canal enlargement.
B) It would be uncommon to take 0.10 and 0.08
tapered ground RNT to the MC. With the TF, 0.10 and
0.08 instruments will be a common master apical
taper. Alternatively, 0.06 is a very common taper with
ground RNT systems. If a 0.04 TF were to be taken
to the MC, it is possible to easily and safely take the
canal preparation to a greater taper, either 0.06 or
0.08 TF, case dependent (Figs. 3,4).
To summarize, in wide open, straight and uncom-
plicated, non-calcified canals, the 0.12 and 0.10 TFs
can be used, as clinically indicated, if inserted pas-
sively to the MC. In more intermediate canals, 0.10
and 0.08 TFs are used. “Intermediate” in this context
means bicuspids or the mesial roots of many average
3/5/09 1:16:50 PM
RO0109_1-52.indd 29 3/5/09 1:16:53 PM
 I trends_ taper and apex locator
Fig. 8_Clinical case treated in the
manner described with a bleeding
point confirmation of the position of
the minor constriction of the apical
foramen.
molar teeth. Whether a 0.10 TF would be used is re-
lated to the iatrogenic risk discussed above. Narrow,
calcified, curved and complex canals will generally
require a 0.08 from orifice to apex with the TF. Canals
of extreme complexity will require a 0.06 taper when
enlarged with the TF.
When using ground RNT instruments, such tapers
cannot be taken to the MC because of their lack of
flexibility. For example, in the mesial root of an aver-
age molar with ground instruments, the 0.10 may be
used at the orifice only, the 0.08 might be taken into
the coronal third of the root and the preparation fin-
ished with a 0.06 taper. This stands in distinction to a
canal preparation with the TF where the entire canal
is prepared to a 0.08 taper or 0.10 taper.
Question 2: My electronic apex locator
(EAL) sometimes gives me unusual read-
ings and I am not sure what to believe.
How can I deal with this?
Locating the true position of the MC is an essential
landmark within the achievement of an endodontic
procedure. If the true position of the MC is located,
the clinician has the potential for optimal cleansing
and shaping. This has significant clinical ramifica-
tions. A multitude of possible iatrogenic issues can
be avoided if the clinician will accurately determine
the initial position of the MC and take steps to avoid
transporting or enlarging the MC; in essence to leave
this natural boundary in the root canal space where
it was originally. Alternatively, if the MC is moved,
transported or changed in any way, iatrogenic out-
comes, such as gross overfilling, extrusion of irrigants
and sealer, etc., are all much more likely to occur. In
addition, the clinician should avoid using RNT files in
the apical third without first accurately determining
the position of the MC. To use RNT of any tip size and
taper in the apical third as pathfinders without first
preparing a glide path is the harbinger of separated
files, canal transportations and iatrogenic issues of
all types (Figs. 5, 6).
The endodontic literature makes several important
clinical considerations that can aid in interpreting the
30 I roots 1_ 2009
RO0109_1-52.indd 30
position of the MC and in TWL determination.
Several studies are cited
1) Radiographic means to determine the posi-
tion of the MC should be viewed with caution as
radiographs only give the relative position of the file
against the root and its relation to the radiographic
apex. Radiographs do not tell the clinician the exact
position of the MC or really anything about the posi-
tion of the file in relation to the apical foramen. The
literature (Williams CB, Joyce AP, Roberts S. A com-
parison between in vivo radiographic working length
determination and measurement after extraction. J
Endod 2006;32:624–627) reports that if a file ap-
pears short on a radiograph, it is actually closer to the
apical foramen than it appears and conversely, when
it appears “long” it is actually further from the apical
foramen than it would appear to be radiographi-
cally. Radiographic working length determination
is fraught with potential problems. These problems
include developmental errors, angulation errors, and
lack of software tools to manipulate and study the
images, among other issues. One study (ElAyouti A,
Weiger R, Löst C. The Ability of Root ZX Apex Locator
to Reduce the Frequency of Overestimated Radio-
graphic Working Length. J Endod 2002; 28:116–119)
found that using radiographs resulted in a reading
that was long approximately 51 percent of the time
and that such error was reduced using an EAL. The
error is derived from the fact that the apical foramen
is often positioned away from the anatomic apex, in
essence, introducing error.
2) The endodontic literature (Venturi M and
Breschi L. A comparison between two electronic
apex locators: an in vivo investigation. Int Endod
J 2005;38:36–45) gives weight to my observation
below that irrigant in the canal affects the readings
and reliability of some machines.
3) Empirically, how an apex locator is used is more
important than the specific EAL. In this study (Tselnik
M, Baumgartner JC, Marshall JG. An evaluation of
Root ZX and Elements diagnostic apex locators. J
Endod 2005;31:507–509), the Elements Diagnostic
Unit (SybronEndo, Orange, Calif.) was compared
with the Root ZX (J Morita, Irvine Calif.). It was found
that there was no statistically significant difference
between the two units. The above notwithstanding, I
have been using the Elements Diagnostic Unit (EDU)
for several years in full-time private endodontic
practice, and it has functioned extremely well. It is
noteworthy that the EDU can also serve as an electric
pulp tester aside from just functioning as an elec-
tronic apex locator (Fig. 7).
By way of definition, an EAL gives the position of
the MC as the file being used in the determination
just passes beyond the narrowest diameter of the
root canal system at the cementodentinal junc-
tion (CDJ). While generally very reliable, there are
3/5/09 1:16:53 PM

several common challenges when using EALs. While
electronic apex locators are marketed as though
they can be used with blood, purulence and sodium
hypochlorite in the canal (among other solutions),
empirically I have found that their accuracy is not as
favorable with liquid in the canals — i.e., they func-
tion better in a dry canal. In addition, in the event of a
faulty reading, the largest file that can reach the MC
should be used, the file should not touch the metal of
the crown (if one is present), and the first thing that
should be done in the event of a faulty reading is for
the clinician to check all of the unit connections to
make certain that they are inserted correctly.
It is essential to appreciate that an EAL reading
should be one of a number of various pieces of con-
firming information to alert the clinician as to the
true position of the MC of the apical foramen. First
off, the clinician should appreciate that the hand file,
which just passes the MC, often gives the clinician the
feeling of a “pop” as it passes out the apical foramen.
The hand file used to accomplish this is small, #6, 8,
10, and is precurved during negotiation of the canal.
If the clinician is careful to make note of the position
of the initial “pop” of a hand file (if one is detected),
he or she will find that this is virtually identical to
the position determined by a subsequent “bleeding
point” with a paper point and the EAL reading. Feel-
ing a tactile “pop” at the MC also has value in telling
the clinician that he or she can negotiate the canal to
the MC and that if the canal patency is subsequently
lost, this was due to something that the clinician
did rather than being due to a calcification or other
blockage that is related to an anatomical challenge
in the root canal system.
While there are as many methods to determina-
tion of true working length as there are clinicians,
what follows are my common methods.
1) I do not take radiographs during treatment
unless there is an imperative reason to do so. From
the initial radiographs, an estimate is made of the
true working length (TWL), this estimated working
length (EWL) is usually very close to the true working
length. The EWL is held in mind until the clinician
_About the author
Richard E. Mounce, DDS
Richard E. Mounce lectures globally and is widely published. He is in private practice in endodontics
in Vancouver, Wash. He offers intensive, customized endodontic single-day training programs in
his office for small groups of doctors. For information, contact Dennis at (360) 891-9111 or write
RichardMounce@MounceEndo.com.
RO0109_1-52.indd 31
trends_ taper and apex locator I
can negotiate the canal by hand to this level with a
small hand file.
2) Once a hand file reaches the EWL, TWL is taken
with the EDU for the first time and instrumentation
commences with the TF, using a taper as described
above. After canal enlargement is completed, the
TWL is taken again with the EDU and canal prepara-
tion finalized. After the preparation is finished, the
EDU is used to reconfirm the TWL. This second deter-
mination of TWL is made because the canal will get
slightly shorter during preparation, although the loss
of length is generally fairly small, 0.5 to 1 mm.
3) After canal preparation is finalized and the EDU
is used as noted above, the EDU measurements are
confirmed with a bleeding point. The bleeding point
is taken with paper points and the position of the MC
of the apical foramen is finalized for the purposes
of obturation using this method in my hands. The
bleeding point is determined using a paper point that
just spots with moisture or haemorrhage at the tip,
generally about 1 mm at the position of the MC. This
spotting is consistent and reproducible.
4) Some clinicians will place the master cone back
from the MC by 0.5 to 1 mm to prevent the extrusion
of sealer and obturation material. If the position of
the MC has been determined accurately, it is optional
and not a step that I personally take. Aside from
creating the correct shape of preparation to the MC,
applying the correct amount of sealer and achieving
excellent cone fit and tugback are all methods to
prevent extrusion.
The answers to two clinically relevant questions
have been discussed to help guide clinicians when
making decisions with regard to the final taper of
their canal preparation as well as to aid in the preci-
sion of the termination point of that obturation.
Emphasis has been placed on creating a taper that
allows adequate irrigation and obturation, but that
does not put the root at risk of a subsequent vertical
fracture or strip perforation. In addition, determining
TWL in a dry canal and understanding the limitations
and capabilities of electronic means of electronic
TWL determination are essential (Fig. 8).
roots
roots
1
_ 2009 I 31
3/5/09 1:16:53 PM
 I trends_ fistulae

Nonsurgical therapy
of mucosal and
cutaneous fistulae
Author_Arnaldo Castellucci, Italy

O
nce the pulp tissue has become
necrotic, the products of cellular
degeneration, bacterial toxins and
occasionally the bacteria themselves
within the canal, spread through the
apical foramen or the various lateral foramina into
the surrounding periradicular tissue.
Fig. 1a_Preoperative radiograph of
the upper left central incisor with a
necrotic pulp caused by preceding
trauma.
A slow inflammatory process thus begins in the
tissue contained within the periodontal ligament. Left
to itself, it may manifest in a variety of ways ranging
from simple widening or thickening of the ligament
to granuloma or cyst.
The increased space of the periodontal ligament in
this area is due to resorption of the surrounding bony
trabeculae with secondary fusion of the connective
tissue of the periodontal ligament with the inter-
trabecular connective tissue of the medullary spaces.
The fibers of the periodontal ligament, which become
disordered and dysfunctional, lose their insertions
in the surrounding bone. However, their insertions
in the cementum, particularly in the periphery of
the lesion, are preserved. The pathological entity
commonly known as a granuloma develops in this
way. Sometimes, the inflammatory process also in-
volves other cellular elements within the periodontal
ligament, namely epithelial rests of Malassez, which,
when stimulated to proliferate, give rise to a cavity
and a radicular cyst.25
In its various clinical manifestations, chronic
apical periodontitis is generally asymptomatic. It is
usually discovered on routine radiographic checkups,
which on occasion is prompted by suspicious discol-
oration of the dental crown. The patient may relate a
history of acute (pulpitic) pain that spontaneously re-
solved or a history of trauma, but he may also present
with a completely unrevealing history. Sometimes,
a fistula may be present, through which the patient
reports having noticed an intermittent discharge of
pus (Figs. 1a–f).

32 I roots 1_ 2009

RO0109_1-52.indd 32 3/5/09 12:29:43 PM

 trends_ fistulae I

Fig. 1b Fig. 1c Fig. 1b_The dental crown is strongly

discolored by hemorrhage secondary
to the trauma. Note the mucosal
fistula.

Fig. 1c_One week following the

cleaning and shaping procedure
only, the fistula has completely
disappeared.

The fistula provides a means of continuous drain-

age of the lesion. This usually prevents reactivations,
either spontaneous or consequent to intervention.
Some authors2,6,10,12,22 are still convinced that the
presence of a fistula indicates a more serious lesion
that requires special intervention, such as surgical
incision and excision of the entire fistulous tract, in
addition to extraction of the diseased tooth (Fig. 2).
In fact, the presence of a fistula should be seen
as a favorable sign, because it is associated with a
number of advantages, so much so that some au-
thors3,8,15,23,24,26,31,32 suggest that if there is none, one
should be created.
It may be extremely helpful in diagnosis. Opaci-
fication of the fistulous tract by the insertion of a
gutta-percha cone clearly demonstrates the diseased
tooth 16 (Figs. 3a–d). The opening of the fistula may
be found on the mucosa overlying the tooth that
sustains it, but it may also often be found at a consid-
Fig. 1d_Postoperative radiograph:
erable distance from the diseased tooth (Figs. 4a–f). the filling has been performed after
Indeed, it may cross the midline, as in cases described Fig. 1d determining clinically that the fistula
by Feiglin9 and Kaufmann.16 had healed
In other situations, the fistula may run in the space
of the periodontal ligament of the same tooth (Fig. 5).
It may even traverse the periodontal ligament of the
adjacent healthy tooth,17 thus simulating a lesion of
periodontal origin (Figs. 6a–d). In such cases, nega-
tive pulp tests performed on the crown of the tooth
indicated by the gutta-percha cone inserted into the
fistula assist in making the correct diagnosis.
Furthermore, healing of the lesion about one week
after cleaning and shaping of the infected root canals
without the use of any medications within the canal
(Figs. 7a–c) confirms that the diagnosis was correct
and testifies to the efficacy of the treatment. This also
suggests a favorable prognosis for the lesion.

Fig. 1e_Appearance of the

dental crown after bleaching.

Fig. 1f
Fig. 1e Fig. 1f_One year recall.

roots
1 _ 2009 I 33

RO0109_1-52.indd 33 3/5/09 12:29:46 PM

 I trends_ fistulae
Fig. 2a
Fig. 2a_The endodontic treatment
of the upper left first molar is
completely inadequate. A gutta-
percha cone is tracing a sinous tract,
originating on the palate, in the area
of the missing second molar.
Fig. 2b_The patient received a
pantomograph...
Fig. 2c_... a computerized
tomography...
Fig. 2d_ ... and a biopsy
(Iperkeratosis and and acute
inflammation!)
Fig. 2e_The prescription for tooth
extraction and the fistulectomy (!)
Fig. 2f_After the removal of
the old restoration, it is evident
the way the access cavity was
previously made: the pulp horns
have been misdiagnosed for
canal orifices and the clinician
forgot to remove a big portion of
the roof of the pulp chamber.
34 I roots 1_ 2009
RO0109_1-52.indd 34
Fig. 2b
Fig. 2c Fig. 2d
Finally, as already suggested, the fistula provides
a means of continuous drainage of the suppurative
contents of the periapical lesion. This discourages
sudden reactivations, either spontaneous or as a
result of our intervention.
If the drainage is not continuous, but rather inter-
mittent, it is preceded by slight swelling of the area as
a result of the increased pressure of pus behind the
closed orifice. When this pressure is great enough to
rupture the thin wall of soft tissue, the suppurative
material issues externally through the small opening
Fig. 2e of the fistulous orifice.11 This orifice may heal and
re-close, only to reopen later. The discharge of pus
is never accompanied by intense pain. At most, the
patient will complain of slight soreness in that area
prior to reopening of the external orifice.
The pus creates a tract in the surrounding tissues,
following the loci minoris resistentiae. It may exit
at any point of the oral mucosa or even the skin.19
It is not uncommon, particularly in young patients,
to find cutaneous fistulae at the level of the mental
symphysis, if lower incisors are involved (Figs. 8a–e),
Fig. 2f or in the submandibular region, if a lower first molar is
involved (Figs. 9a–e), or in the floor of the nasal fossa,
3/5/09 12:29:48 PM
Website_AD_A4 04.03.2009 15:49 Uhr Seite 1

DENTAL TRIBUNE The World’s Dental Newspaper

The first worldwide online newspaper aimed

at dental professionals and the dental industry
is now online!

online
now!

International News & Politics ■ Discussions

Clinical Features ■ Videos & Blogs
Products ■ Events

www.dental-tribune.com
 I trends_ fistulae

Fig. 2g_Postoperative radiograph.

Fig. 2g

Fig. 2h_The fistula is healed.

Fig. 2h Fig. 2i
Fig. 2i_Six-month recall.

if a central incisor is involved.13,30 ticularly esthetic — of such an intervention, is not

Cutaneous fistulae, which unfortunately are
sometimes treated as though they were independ-
ent dermatologic lesions, have the same pathogenic
and prognostic significance as mucosal fistulae
and require the same therapy.21,33 A review of the
literature5,7,18,29 reveals that patients with cutaneous
fistulae are sometimes subjected to repeated surgical
excisions and biopsies (Fig. 2d) before it is clear that
the fistula is none other than an extension of pulp
disease in the periradicular tissues.
Trying to treat such lesions with a circular incision
of the orifice of the cutaneous fistula and excision
of its entire tract, with all the ramifications — par-
consistent with the present standard of care and can
be considered pure folly.
These fistulae simply require identification of the
diseased tooth, whose root canal system must be
cleaned and shaped.
If the tooth presents any obstacles to nonsurgical
treatment or retreatment, or if the patient specifically
requests surgery, one may proceed surgically, but
one’s attention must be directed solely to achiev-
ing a retrograde apical seal, and not eliminating the
fistulous tract or its cutaneous orifice (Figs. 8a–e).
The reason why some authors believe in the need
for surgical removal of the fistulous tract lies in the

Fig. 3a_Preoperative radiograph

of the upper right first and second
molars. Note the round radiolucency
between the mesiobuccal root of the
second molar and the distobuccal
root of the first. The patient had
presented with a vestibular fistula
at the level of the first molar, and
for financial reasons only wanted to
Fig. 3a Fig. 3b
retreat the diseased tooth.

Fig. 3b_A gutta-percha cone

placed in the fistula indicates that
the fistulous tract arises from the
second molar.

Fig. 3c_Postoperative radiograph of

the second molar. Note that a small
lateral canal in the mesiobuccal
root, which was apparently
responsible for the lesion seen in the
preoperative film, has filled up.
Fig. 3c Fig. 3d
Fig. 3d_Five-year recall.

36 I roots 1_ 2009

RO0109_1-52.indd 36 3/5/09 12:29:49 PM

 trends_ fistulae I

Fig. 4a_This young patient

presented with a fistula between
the canine and lower right first
premolar. A gutta-percha cone has
been inserted into the fistulous tract.

Fig. 4b_Radiographically, the gutta-

percha cone seems to implicate the
lateral incisor as the diseased tooth.
All the teeth heretofore identified
Fig. 4a Fig. 4b have responded positively to the
vitality tests.

Fig. 4c_Deeper insertion of the

gutta-percha cone finally identifies
the two lower central incisors as
the diseased teeth. Both respond
negatively to the various vitality
tests.

Fig. 4c Fig. 4d Fig. 4d_One week after cleaning

and shaping, the fistula has closed.

Fig. 4e_Postoperative radiograph.

Fig. 4e Fig. 4f
Fig. 4f_Two-year recall.

Fig. 5_Preoperative radiograph of a

necrotic lower left second premolar
with a fistula opening into the space
of the periodontal ligament. A gutta-
Fig. 5 percha cone has been inserted into
the fistula.

Fig. 6a_The periodontal probe

disappears in the sulcus of the
canine in a patient with good oral
hygiene and healthy periodontium in
the different quadrants. The canine
responds positively to the tests of
vitality, while the lateral incisor is
necrotic.

Fig. 6b_Preoperative radiograph

of the lateral incisor. Note that the
Fig. 6a Fig. 6b lesion “rests” on the mesial side of
the root of the adjacent canine.

roots
1 _ 2009 I 37

RO0109_1-52.indd 37 3/5/09 12:29:55 PM

 I trends_ fistulae

Figs. 6c_Clinical appearance of

the canine gingiva one week after
cleaning and shaping of the lateral
incisor.

Fig. 6c
Figs. 6d_Postoperative radiograph.

mistaken conviction that it is lined by an epithelium.28

Grossman11 states, however, that such tracts are lined
by granulation tissue: in his study, he was unable to
identify any epithelium at all.
Bender and Seltzer4 have also made histologic
studies of numerous fistulous tracts without finding
an epithelial lining.
Other authors1,14,31 agree that the fistulous tract
may be lined by flat, multilayered epithelial cells, but
that more often it is lined by granulation tissue, with
acute and chronic inflammatory cells.
Given the current state of knowledge, there is Fig. 6d
no reason to recommend surgical removal of such
tracts. There is no reason that even epithelium-lined
fistulous tracts should not heal after appropriate endodontic therapy.
When it is present, the epithelium may arise from
the oral mucosa or proliferating epithelial cells from
the periapical lesion. However, there is no correlation
between the presence or absence of an epithelium
and the clinical appearance of the fistula or its chro-
nicity.
In animal experiments, Ordman and Gillman20
have demonstrated that cutaneous sutures may
become completely epithelialized if the sutures are
left in place for several weeks. Once they are removed,
however, the epithelium-lined tract always heals
completely.
There is no reason that the same should not hap-
pen to the possibly present epithelium of the fistula
Fig. 7a of a necrotic tooth once the inflammatory stimulus
is removed.
Figs. 7a_Fistula corresponding to
the upper left central incisor.

Figs. 7b_Healing of the fistula one

week later. The canal has been
cleaned, shaped, and irrigated with
sodium hypochlorite, while the pulp
chamber has been medicated with
Cresatin and Cavit. In other words,
it has been treated as though the
fistula did not exist. Its resolution
confirms that the diagnosis and
therapy were correct and justifies
proceeding with three-dimensional
filling of this root canal system.
Fig. 7b Fig. 7c
Figs. 7c_Another view one year later.

38 I roots 1_ 2009

RO0109_1-52.indd 38 3/5/09 12:30:01 PM


Fig. 8a
Obviously, these fistulae must be distinguished
from congenital fistulae of the neck, both lateral
(arising from the second branchial cleft) and medial
(arising from rests of the thyroglossal duct), which are
lined by an epithelium. Such fistulae, however, have a
different pathogenesis and obviously do not resolve
spontaneously, but only after careful surgical exci-
sion of the entire tract.27 The differential diagnosis
includes the following:13,21
W localized infections of the skin, such as pyo-
derma, pimples, ingrown hairs, and obstructed
sweat glands,
W traumatic or iatrogenic lesions,
W osteomyelitis,
W neoplasia,
W tuberculosis,
W ctinomycosis.
Conclusion
Endodontic lesions with a fistulous tract should
always be welcome in our office. And this is true for
many reasons:
W The tooth responsible is necrotic, therefore the
patient does not need any anesthesia, which
means that while we make the access cavity, at
the same time we perform the most important
and the most reliable vitality test, the cavity test.
W The insertion of a gutta-percha cone in the
fistulous tract will help in the diagnosis: the
radiograph will immediately show the tooth
responsible.
W The patient will never have a flare up. The re-
crudescence after treatment or retreatment is
nothing more than one little drop of pus coming
out from the fistula, and the patient is not even
aware of it.
W One week after cleaning and shaping of the root
canal system, the fistula is gone, and this will
confirm that we made the right diagnosis and
RO0109_1-52.indd 39
trends_ fistulae I
Fig. 8a_Cutaneous fistula in the
mental region.
Fig. 8b_Preoperative radiograph
of the lower incisors. The patient
elected surgical therapy for
economical reasons. The left lateral
Fig. 8b incisor had already been subjected
to a cavity test.
Fig. 8c_Postoperative radiograph.
Three apicoectomies with amalgam
retrofilling have been performed. Not
the least attention has been paid to
removal of all the granulation tissue
or to curettage of the surrounding
bone or apices, or to removal of the
fistulous tract, or even to circular
Fig. 8c incision of the cutaneous orifice of
the fistula.
Fig. 8d_Complete healing of the
Fig. 8d cutaneous fistula without any
residual scarring after two years.
Fig. 8e_Radiograph two years later
Fig. 8e confirms total resolution of the
previous radiolucency.
the right treatment.
The presence of a fistula, in conclusion, is not an in-
dication for extraction, is not an indication for surgery,
is not an indication for any specific medication: it is
just an indication for a correct root canal treatment.
References:
1. Baumgartner, J.C., Picket, A.B., Muller, J.T.: Microscopic examina-
tion of oral sinus tracts and their associated periapical lesions.
J. Endod. 10:146, 1984.
2. Bella, G., Russo, S., Messina, G., Badalà, A.: Considerazioni sulle
roots
1 _ 2009 I 39
3/5/09 12:30:03 PM
 I trends_ fistulae
Figs. 9a_Cutaneous fistula in the
right submandibular region.
Figs. 9b_Preoperative radiograph of
the ipsilateral lower first molar. The
tooth had been “opened” one month
before and left open “to drain.” Note
the small radiopacity at the center of
the access cavity, due to a residuum
of the chamber roof left in place.
Figs. 9c_Clinical appearance of the
access cavity: three openings have
been made in the roof of the pulp
chamber! One, corresponding to the
distal canal, is shaped like a figure
8. The two round ones correspond
to the mesial canals: The pulp horns
have been misdiagnosed for canal
orifices.
Figs. 9d_Postoperative radiograph.
The tooth has been pretreated with a
cooper band.
Figs. 9e_Healing of the fistulous
tract two years later. Note the
complete absence of any scarring.
40 I roots 1_ 2009
RO0109_1-52.indd 40
fistole cutanee odontogene. Il dentista moderno, 10:2353,
1989.
3. Bence, R.: Trephination technique. J. Endod. 6:657, 1980.
4. Bender, I.B., Seltzer, S.: The oral fistula: its diagnosis and treat-
ment. Oral Surg. 14:1367, 1961.
5. Braun, R.J., Lehman, J.: A dermatologic lesion resulting from
a mandibular molar with periradicular pathosis. Oral Surg.
52:210, 1981.
6. Calvarano, G., De Paolis, F., Bernardini, G.: Fistole cutanee e
salivari: soluzioni terapeutiche. Odontostomatologia e Implan-
toprotesi, 1:82, 1991.
7. Cioffi, G.A., Terezhalmy, G.T., Parlette, H.L.: Cutaneous draining
sinus tract: an odontogenic etiology. J. Am. Acad. Dermatol.
14:94, 1986.
8. Elliot, J.A., Holcomb, J.B.: Evaluation of a minimally traumatic
Fig. 9a alveolar trephination procedure to avoid pain. J. Endod. 14:405,
1988.
9. Feiglin, B.: Pain and fistulas can cross the midline. J. Endod.
11:132, 1985.
10. Galli, S., Galli, G.: Considerazioni anatomiche e cliniche su un
caso di fistola odontogena. Odontostomatologia e Implanto-
protesi, 6:50, 1989.
11. Grossman, L.I., Oliet, S., Del Rio, C.E.: Endodontic practice. 11th
ed. Lea & Febiger, Philadelphia, 1988.
12. Harnisch, H.: Apicectomia. Scienza e Tecnica Dentistica. Edizioni
Internazionali. Milano, 1981.
13. Heling, I., Rotstein, I.: A persistent oronasal sinus tract of endo-
dontic origin. J. Endod., 15:132, 1989.
14. Ingle, J.I.: Endodontics, Lea & Febiger, Philadelphia, 1965, pp.
361–362,441.
Fig. 9b 15. Ingle, J.I.: Endodontics, 3rd ed. Lea & Febiger, Philadelphia,
1985.
16. Kaufman, A.Y.: An enigmatic sinus tract origin. Endod. Dent.
Traumatol. 5:159, 1989.
17. Kelly, W.H., Ellinger, R.F.: Pulpal-periradicular pathosis causing
sinus tract formation through the periodontal ligament of
adjacent teeth. J. Endod. 14:251, 1988.
18. Lewin-Epstein, J., Taicher, S., Azaz, B.: Cutaneous sinus tract of
dental origin. Arch. Dermatol. 114:1158, 1978.
19. Mcwalter, G.M., ALEXANDER, J.B., Del RIO, C.E., KNOTT, J.W.:
Cutaneous sinus tracts of dental etiology. Oral Surg. 66:608,
1988.
20. Ordman, L.J., Gillman, T.: Studies in the healing of cutaneous
wounds. II. The healing of epidermal, appendageal and dermal
Fig. 9c injuries inflicted by suture needles in the skin of pigs. Arch. Surg.
93:883, 1966.
21. Pagavino, G., Pace, R., Giachetti, L.: Le fistole cutanee odon-
togene: diagnosi e tarapia, R.I.S., Anno LIX, 11/12:6, 1990.
22. Palattella, G., Mangani, F., Palattella, P., Palattella, D., Mauro, R.:
Fistole cutanee da estrinsecazioni perimandibolari di parodon-
titi apicali croniche. Dental Cadmos 2:57, 1987.
23. Peters, D.D.: Evaluation of prophilactic alveolar trephination to
avoid pain. J. Endod. 6:518, 1980.
24. Sargenti, A.: Apical aeration made easy by a new instrument. J.
Br. Endod. Soc. 6:49, 1972.
25. Schilder, H.: Endodontic therapy, in: Current therapy in Den-
tistry. Goldman et Al. eds., vol. I, St. Louis, The C.V. Mosby Com-
pany, 1964, pp. 84–102.
Fig. 9d 26. Seldon, H.S., Parris, L.: Management of endodontic emergencies.
J. Dent. Child. 37:260, 1970.
27. Sicher, H.: Orban’s Oral Histology and Embriology, ed. 6, St. Louis,
The C.V. Mosby Company, 1966, pp. 1–17.
28. Sommer, R.F., Ostrander, F.D., Crowley, M.C.: Clinical Endo-
dontics, 3rd ed., W.B. Saunders Company, Philadelphia, 1966,
p. 306.
29. Spear, K.L., Sheridan, P.J., Perry, H.O.: Sinus tracts to the chin and
jaws of dental origin. J. Am. Acad. Dermatol. 8:486, 1983.
30. Strader, R.J., Seda, H.J.: Periapical abscess with intranasal fistula.
Oral Srg. 32:881, 1971.
31. Weine, F.S.: Endodontic therapy, 2nd ed., The C.V. Mosby Com-
pany, St. Louis, 1976.
32. Wolch, I.: A new approach to the basic principles of endodontics.
Int. Dent. J. 25:179, 1975.
33. Zerman, N., Urbani, G., Menegazzi, G., Cavalleri, G.: Il trattamento
Fig. 9e di fistole cutanee da lesioni endodontiche. Il Dentista Moderno
7:1381, 1990.
3/5/09 12:30:06 PM
   


  

_About the author roots
  

Dr. Arnaldo Castellucci
Dr. Castellucci graduated in
medicine at the University of
Florence in 1973 and special-
ized in dentistry at the same
University in 1977. From 1978
to 1980 he attended continuing
education courses in endodon-
tics at Boston University School
of Graduate dentistry with Prof.
Herbert Schilder. As well as running a practice limited to en-
dodontics in Florence, Italy, Castellucci is past president of the
Italian Endodontic Society, past president of the International
Federation of Endodontic Associations, an active member of
the European Society of Endodontology, an active member
of the American Association of Endodontists, and a visiting
professor of endodontics at the University of Florence Dental
School. He is editor of The Italian Journal of Endodontics and of
The Endodontic Informer, founder and president of The Warm
Gutta Percha Study Club and The Micro-Endodontic Training
Center, and he is international editor of Endo Tribune. An in-       
ternational lecturer, he is the author of the text “Endodontics,”
which is now available in English.

  
   

 
    
  

   
 
 
  

  

 

 

 
 


  !  
 




 



  

 
   
,   
 !"
#! !$ %$!"


 

- (.'/0,0,



 ,


#&!'
! ()** $!
 

1  
   
"!# !"$%

&' 0  ,
 *%# *"!
This article is an excerpt from !"%

&
  '
Dr. Arnaldo Castellucci’s textbook
“Endodontics,” which is divided into
   
three volumes and 35 chapters.
   !"#$$
%&'
'#(' )*&$+
&+(
+%&%
Volumes 1 and 2 of this endodontic
textbook are now available for the 
 
 
  
first time in English, completely
revised with new chapters and many
more color illustrations. Each volume 

   
( )  *
comes complete with its own CD-     

  
+* 
ROM, which includes the complete 
    
      
text and illustrations in PDF files. 



    
 
 
To order, contact Il Tridente S.R.L., 
   , 

Viale dei Mille 60, 50131 Firenze,    
 

Italy, Tel. +39 055 500 1312,  


 

 



Fax +39 055 500 0232, info@

 

iltridente.it, or visit www.iltridente.it.



"!# !+-

&'.
!+-"/

& '

RO0109_1-52.indd 41 3/5/09 12:30:08 PM

 I research _ ceramics-based sealers

Ceramics-based sealers
as new alternative
to currently used
endodontic sealers
Authors_ Deyan Kossev & Valeri Stefanov, Bulgaria

Fig. 1_Polarisation microscopy.
Horizontal cut. Dark green — dentin,
white — bioceramic-based sealer
iRoot SP, orange — gutta-percha
cone.
T
he most ideal outcome of an endodon-
tic treatment is hard tissue closure,
which permanently separates the root
canal content — the root filling — from
the periapical tissues and prevents
chronic irritation and foreign body reactions by
material components.7 Good instrumentation and
cleaning of root canal combined with perfect
hermetic closure of its apical third are decisive
preconditions for achieving of full closure of root
canal apical orifice with cementoid tissue. Closure of
the root canal in this way ensures non-problematic
and long-term function of the root in naturally wet
environment surrounding it.
Today’s “golden” standard for endodontic treat-
ment are warm condensation multi phase (gutta-
percha — sealer ) techniques. These techniques,
however, result in a friction fit, “cork-in-the-bottle”
type sealing only. In the era of adhesive techniques
in dentistry we have an endodontic standard, which
lacks adhesion and chemical bond between root canal
dentin walls and root canal filling materials. Visualiza-
tion of sealer “puff” in periapical space on radiography
does not give enough grounds to say that seemingly
adequate root canal filling is an absolute guarantee of
successful healing result.1 Shrinking of gutta-percha
after the end of warm condensation and lack of adhe-
sion of the root filling materials to dentinal root canal
walls are factors creating enough predispositions
for micro leakage. The known fact is that the hu-
man body’s immune system can easily deal with this
situation when titer of microorganisms is low. That
capability of immune system is demonstrated by lack
of periapical pathology and subjective complaints.
This equilibrium can easily be destroyed when due to
different reasons human body’s reactivity is changed
and existing balance is “pushed” toward appearance of
pathologic periapical changes.
That is why the quest for endodontic sealers that
adhesively and chemically bond to root canal walls
continues. Clinical use of Bis-GMA based sealers in
combination with polycaprolactone made cones is a
promising step ahead,5,10 but in the area of the root
canal apical third these materials are in constant
contact with wet environment of periodontium and
are subjected to action of enzyme systems there.
Reported data about alkaline and enzyme hydrolysis
of polycaprolactone and the shrinkage of Bis-GMA
based sealer question the long-term stability of api-
cal third hermetic seal achieved by these endodontic
sealers.2,8,9
‘Endodontic grafting’
Filling of the root canal apical third must be looked
upon separately from the filling of the rest of the canal
having under consideration the active and constant
metabolic processes occurring in the periapical area.
Special attention must be paid to the interface formed
between dentinal root canal walls, gutta-percha and
sealer on one side and periodontium and body fluids
on the other side. Long-term hermetic sealing of apical
third achieved in constantly wet environment is an ob-
ligatory condition to ensure lack of microbial growth.
Another extremely important factor promoting hard
tissue closure of the canal is presence of osseocon-
ductivity as sealer’s feature. Perfect and lasting in wet
environment hermetic seal of apical third combined
with osseoconductivity of endodontic sealer ensure

42 I roots 1_ 2009

RO0109_1-52.indd 42 3/5/09 11:55:29 AM


conditions for hard tissue closure of root canal apical
orifice in time. Filling of the root canal with ceramic
sealer, which due to its osseoconductivity action
promotes the physiological closure of the canal by
cementoid hard tissue, can be called “endodontic
grafting.” Such endodontic grafting can ensure the
lasting root’s health while it constantly remains in
contact with body fluids.
The use of bioceramic-based sealers with their fea-
tures — osseoconductivity, hydrophylity, adhesiveness
and chemical bonding to root canal dentinal walls —
appears to be an effective approach to eliminate (Fig.
1) on long term, the microspace, otherwise remaining
between the root canal walls and the materials filling
the root canal. Such microspace is a potential place for
possible microbial growth, because of microleakage
observed with other kind of sealers.
Sealers for ‘endodontic grafting’
Endodontic sealers that set hard and are stable in
constantly wet environment are :
a. Recently created calcium — silicate — phos-
phate-based bioceramic nano-compositions — Bio-
Aggregate, iRoot SP and iRoot BP (IBC, Canada).
b. MTA-based products — “MTA — Angelus” (AN-
GELUS, Brazil), ProRoot (Dentsply, USA), Aureoseal
(OGNA, Italy).
The common feature of all these products is that
when used to fill the apical third of the root canal, they
guarantee adhesive hermetic seal.4 They do not get
destroyed during their hardening and afterward while
being constantly in contact with the wet periapical
environment. They are very stable in time. Ceramic-
based sealers ensure much better apical seal than IRM,
amalgam or Super EBA materials, and this excellent
seal is combined with excellent biocompatibility and
significant stimulation of periodontal regeneration.5,6
Until recently the application of all these materials,
except for iRoot SP and iRoot BP, required significant
widening of the root canal apical third — up to #60–70
— and use of specially developed instruments to carry
the materials to apical third of the canal. These purely
technological limitations were reducing ceramic-
based materials use as regular antegrade root canal
filling materials.
The first author has developed an innovative
method for filling of apical third of the root canal with
MTA- and bioceramic-based sealers he has called the
“capillary condensation” technique. This new tech-
nique does not require enlargement of the canal’s
apical third more than  # 35-40 / 04. Apical third of
canal space is widened based on its original size and
shape only.
Method for ‘capillary condensation’ of
ceramics-based endodontic sealers to fill
the root canal
Method comprises of several stages:
RO0109_1-52.indd 43
research _ ceramics-based sealers I
I. Preparation of “coronal reservoir” from which
ceramic sealer to be condensed aside to canal walls
and toward and into canal’s apical third so that to seal
the canal’s apical orifice.
Using RGG or GG drills, the coronal third of the
root canal is conically widened to form a “coronal
reservoir,” which is subsequently to be filled with MTA,
BioAggregate, iRoot SP or iRoot BP material.
From this point on, there are two different ap-
proaches:
A. “Coronal reservoir” is filled directly with ready-
Fig. 2_Plastic applicator inside
to-use material packed into syringes (iRoot SP or iRoot simulated root canal “coronal
BP). Mini applicators included in the package are used reservoir.”
for direct filling of reservoir with factory premixed
material.
B. Powder-like ceramic material (MTA or biocer-
amic-based BioAggregate) is mixed with distilled wa-
ter to form a paste with suitable viscosity to allow car-
rying it into the “reservoir” by plastic carrier designed
by the author. Micro applicator handle, with “fluffy”
head cut, may be used instead, too. (Fig. 2)
The dentist can fold the plastic carrier as needed
to make it suitable to easily get inside the “coronal
reservoir.” Small portions of “ex tempore” mixed sealer
are carried into the “reservoir” until it gets full. It is im-
portant to work in constantly slightly wet root canal.
Before putting next small portion of MTA or BioAggre-
gate sealer into reservoir, the dentist visually controls
the moisture of the sealer mass. If necessary the tip of
the plastic carrier is wetted with distilled water and
put inside the reservoir to increase the humidity of the
sealer mass inside. Thus the risk of drying of material
at the bottom of the reservoir is avoided and ceramic Fig. 3_Condensor inside simulated
sealer is prepared for condensation further inside the root canal down to 1 mm less than
root canal. WL.
II. “Capillary condensation” of the sealer to fill the
root canal
This stage is valid for both (A and B) types of ce-
ramic sealers. Condensation of the sealer is made with
“condensor” — an instrument designed by the authors
(Fig. 3). The basic rule is correctly chosen instrument
to get freely inside into root canal within 1 mm less
than canal’s measured working length (WL). In case of
straight canals the number (#) of the instrument must
be one number (#) less than MAF. In slightly or severely
curved canals the number (#) of the used instrument
must be two to three numbers (#) less than MAF. It is
preferable to use NiTi made instruments, especially in
curved canals.
By pushing the condensor slowly in and then get-
ting it out, without taking it totally out of “coronal
reservoir,” the sealer is condensed inside the canal,
aside to canal’s walls and at the same time toward its
apical orifice, down to previously defined depth of 1
mm less than WL. Condensation must be done slowly Fig. 4_Condensor in the moment of
and with maximum possible amplitude of the “push- “take-out” movement start (compare
in” and “take-out” movements (Fig. 4). to Fig. 3).
roots
1 _ 2009 I 43
3/5/09 11:55:30 AM
 I research _ ceramics-based sealers
When condensing the powder-like ceramic seal-
ers (MTA-based or BioAggregate) that are mixed “ex
tempore” before use, there should not be a tactile
feeling of “tightening” of the instrument inside the
canal during condensation. If such a feeling appears,
the dentist must take the condensor totally out of the
canal and must wet the tip of the instrument with wa-
ter before inserting it inside the canal again. The total
time for the sealer’s condensation is approximately
10–15 seconds. Between 12 and 15 “push-in/take out”
movements are needed to achieve a good filling of the
canal’s apical third and to ensure good adhesion of the
sealer to canal’s walls, too. Ten seconds after the start
of condensation (approximately 10 “push-in” move-
ments) the dentist must take the instrument out of
canal. There should not be hardened aggregates on
the instrument’s surface, but only liquid white solu-
tion. Then one must look at the bottom of the “coronal
reservoir.” If there is a “black hole,” this means more
water must be added to the sealer inside the reservoir.
The tip of plastic carrier is wetted with water and is put
inside the reservoir. This is to be immediately followed
by adding one more small portion of the mixed sealer
into the reservoir. Important note: Do not add water
when using bioceramic-based iRoot SP and iRoot BP
sealers! Only the additional portion of sealer must be
added when using iRoot SP or iRoot BP! These two
sealers are supplied premixed and “ready to use” and
do not need additional water, they have already been
factory mixed to optimal viscosity to fill the canal
properly.
III. Insertion of gutta-percha cones
At the moment of choosing the correct size con-
Clinical application of ‘capillary condensation’ technique
1. Filling with MTA
Fig. 5a Fig. 5b
Fig. 5a_Before (Rx made on Nov.
24, 2006) Fig 5b_After (Rx made on March 30, 2007) Fig. 6a_Before (Rx made on June 8, 2006) Fig. 6b_After (Rx made on June 25, 2006)
44 I roots 1_ 2009
RO0109_1-52.indd 44
densor, the dentist must also choose the same size
gutta-percha master cone. Inserting of the gutta-
percha cone inside the canal will serve three functions
simultaneously.
A. It will finish the condensation of the sealer
inside the root canal and will make sealer layer along
the canal’s length even. It will eliminate any air still
entrapped inside the canal, too.
B. It will create a pliable space inside the canal with
which to accommodate the stress created by expan-
sion of the ceramic sealers during their hardening.
Bioceramic-based sealers BioAggregate, iRoot SP and
iRoot BP have significant expansion of 0.20 percent.
C. By inserting the gutta-percha cones the pos-
sibility for re-entering the canal is maintained, and
easier preparation of calibrated “bed,” for cementing
a fiberglass post inside, is ensured.
The master gutta-percha cone is inserted slowly
with “push-in” and “take-out” motions down to 1
mm less than WL. Additional smaller diameter gutta-
percha cones may be added, if necessary. The ends of
gutta-percha cones extending out of the root canal
are cut and cones are condensed with round head
metal instrument. During gutta-percha condensa-
tion excessive water and excessive sealer remnants
are also pushed outside and are wiped out with small
cotton pellet. A temporary filling is placed in the tooth
cavity. After the ceramic sealer is hardened, preferably
24 hours after canals are filled, the final restoration
is made.
Fig. 6a Fig. 6b
3/5/09 11:55:30 AM
 research _ ceramics-based sealers I

2. Filling of root canals with BioAggregate.

Fig. 8b_After — see the difference

Fig. 7a Fig. 7b
in radiopacity of gutta-percha cones
Fig. 8a Fig. 8b and bioceramic-based BioAggregate
Fig. 7a_Before. Fig.7b_After — three mesial sealer (arrows).
canals filled. Fig. 8a_Before.

Features of ceramic-based endodontic

sealers
1. Ceramic-based sealers are highly hydrophilic
and have low contact angle. These features allow them
to spread easily over the dentin walls of the root canal
and to get inside and fill the lateral micro canals, too.
Thus necessity to instrument the canals with 06 or
higher taper becomes no longer needed. Tooth tissues
are preserved, and risk of root fractures is reduced.
Very well-filled lateral micro canals can be seen on
experimental samples. Filling is done with iRoot SP
(Figs. 12, 13).

Fig. 9a Fig. 9b

Fig. 9a_Before. Fig. 9b_After.

3. Filling of root canals with iRoot SP. Note excellent

radiopacity of this bioceramic sealer.

Fig. 12_Small micro canal filled

with iRoot SP (arrow). Horizontal cut.
Fig. 12 Polarisation microscopy. Black —
root dentin, white — iRoot SP sealer,
orange — gutta-percha cone.

Fig. 10a Fig. 10b

Fig. 10a_Before. Fig. 10b_Three weeks after

filling.

Fig. 13_Lateral micro canal with an

Fig. 13 additional branch perfectly filled by
iRoot SP sealer (arrows). Horizontal
cut. Polarisation microscopy. Black
— root dentin, white — iRoot SP
2. During setting hard ceramic-based sealers inside micro canal.
expand. Expansion of BioAggregate and iRoot SP
and iRoot BP is significant — 0.20 percent. These new
bioceramic sealers also form chemical bond with the
Fig. 11a Fig. 11b canal’s dentin walls. That is why no space is left be-
tween the sealer and dentin walls. This is well demon-
Fig. 11b_One month after the strated by light polimerization microscopy and much
Fig. 11a_Before. filling. better demonstrated by large magnification scanning

roots
1 _ 2009 I 45

RO0109_1-52.indd 45 3/5/09 11:55:32 AM

 I research _ ceramics-based sealers

relatively small or totally absent. Such lack of pain

Fig. 14
Fig. 14_Polarisation microscopy.
Horisontal cut. S — Bioceramic
sealer iRoot SP. D — Root dentin.
Fig. 15_SEM x 5000. iR —
bioceramic sealer iRoot SP.
D-dentinal tubules of root canal wall.
Points bar is equal to 10 microns.
Distance between dots is equal to
1 micron only. White arrow shows
the interface between sealer and
dentin without presence of any voids
because of chemical bond between
dentin and sealer.
Fig. 16a_Right after filling (Rx made
on Dec. 19, 2008).
Fig. 16b_Note significant bone
recovery only 20 days after filling (Rx
made on Jan. 9, 2009).
Fig. 17a_Large diffuse exacerbated
periapical bone lesion. After
instrumentation and cleaning root
canals were filled with CaOH for three
days with no improvement. After third
day CaOH was removed and canals
were cleaned and filled directly with
iRootSP. Pain was gone in several
hours after the filling with iRootSP
was done and palpable intraorally
subperiosteal swelling was resolved
totally within 24 hours (Rx made on
Dec. 16, 2008).
Fig. 15
electron microscopy (Figs. 14, 15).
3. Bioceramic-based sealers are capable of achiev-
ing fast alleviation of the pain syndrome in cases
of acute periapical inflammation. After appropriate
instrumentation and cleaning of the root canal, fol-
lowed by immediate filling with iRoot SP, pain rapidly
diminishes and most often is totally gone within a
period of 50 minutes to few hours.
4. In cases of MTA-based materials extrusion
outside the root canal is associated with severe pain
felt by the patient. When bioceramic-based sealers
BioAggregate or iRoot SP are extruded, the pain is
Fig. 16a Fig. 16b
may be explained with the characteristics of these
new materials. During hardening they “produce”
hydroxylapatite and after the end of hardening proc-
ess they exhibit the same features as non-resorbable
hydroxylapatite-based bioceramics used for bone
replacement in oral surgery. Due to the hydroxyla-
patite formed, they are also osseoconductive (Figs.
16–18).
5. MTA-based materials and BioAggregate have
quite poor radiopacity, different from bioceramic
based iRoot SP and iRoot BP sealers. This difference
is easily demonstrated by the following experiment.
Root canals of extracted teeth have been instru-
mented with TF files (SybronEndo) and cleaned. Two
of the canals were filled with iRoot SP, and the other
two with BioAggregate, respectively (Fig. 19). Note
the excellent radiopacity of iRoot SP (left) compared
to BioAggregate (right).
When roots’ apical thirds of same tooth, which
does not contain gutta-percha, were cut and investi-
gated under polarization microscopy, no difference in
quality of achieved canal seal have been found (Figs.
20, 21).
Based on the above findings, it is preferable that
bioceramic-based iRoot SP sealer be used for “endo-
dontic grafting” (i.e., filling of root canals) because of
its excellent radiopacity. It is not possible to verify the
quality of root canal filling achieved with MTA-based
materials or BioAggregate using radiographies only,
due to poor radiopacity of these materials.
Discussion
Cantatore3 define ideal conditions for endodontic
sealers as follows:
1. Adequate consistency and adhesion to dentinal
walls

Fig. 17b_Only three weeks later, a

significant bone lesion improvement
can be seen, too (Rx made on Jan.
9, 2009).
Fig. 17a Fig. 17b
Fig. 18a_Periapical bone lesions
around roots of lower incisors (Rx
made on Jan. 7, 2008).

Fig. 18b_Significant bone recovery

is seen just about one month after
canals were instrumented, cleaned
and filled with BioAggregate. Lateral
incisor was instrumented, cleaned
and filled with iRootSP due to an
acute pulpitis (iR). In fact second
radiography was made to evaluate
the filling with iRootSP, but revealed
nice bone healing around central
incisors for such a short period of Fig. 18a Fig. 18b Fig. 19
time, too (Rx made on Feb. 11, 2008).

46 I roots 1_ 2009

RO0109_1-52.indd 46 3/5/09 11:55:33 AM


2. Adequate working time.
3. Capacity to produce a hermetic seal.
4. Easy handling.
5. Radiopacity.
6. Expansion at the time of set.
7. Antibacterial action.
8. Biocompatibility.
9. Insolubillity in tissue fluids.
10. To allow retreatment of the canal.
11. Do not discolor dental tissues.
12. No antigenic action.
13. No mutagenic action.
Sealers routinely used in endodontics and based
on epoxy resin, calcium hydroxide, glass ionomer, zinc
oxide — eugenol, formalin-resorcine pastes, polyc-
aprolactone and Bis-GMA ± do not meet one or more
of above listed requirements.
MTA-based materials (MTA-Angelush, ProRoot —
Dentsply, Aureoseal — OGNA) exhibit good adhesion
to dentinal walls of root canal, but until recently they
required very big enlargement of canal’s apical third
to be easily applied. With the method for “capillary
condensation” developed by the first author for filling
of root canals, these materials became easy to apply
into the canal space.
Bioceramic-based materials having nano-sized
particles (BioAggregate, iRoot SP, iRoot Bp) achieve
excellent adhesion to the canal’s dentinal walls and,
more importantly, form a chemical bond with dentin.
Structure of these materials during their mixing with
water allows a very good consistency to be achieved
(BioAggregate) or optimal consistency is already
guaranteed by manufacturer by offering premixed
“ready-to-use” products (iRoot SP, iRoot BP). All ce-
ramic-based sealers are hardening slowly. This feature
gives the dentist the possibility to do corrections of the
filling, if control radiography has revealed any prob-
lems. Due to their hydrophilicity and low contact an-
gle, all ceramic-based sealers achieve extremely good
hermetic seal. All MTA- and bioceramic-based sealers
are quite easy to use when the dentist has mastered
the “capillary condensation” technique for filling of
root canals. MTA-based materials and BioAggregate
have poor radiopacity, differently from iRoot SP and
iRoot BP. All ceramic-based sealers expand during the
time of set. They exhibit potent antimicrobial action,
too. All ceramic sealers are biocompatible and insolu-
ble in tissue fluids. They have not demonstrated until
now any antigenic or mutagenic action. When used
in combination with gutta-percha cones, re-entering
of the canal space is possible and a calibrated “bed”
may be drilled to accommodate a fiberglass post into
the canal.
Conclusions
Potent antibacterial activity, absolute biocompat-
ibility, osseoconductivity, ability to achieve excellent
hermetic seal in constantly wet environment, for-
RO0109_1-52.indd 47
research _ ceramics-based sealers I
Fig. 20 Fig. 21
Fig. 20_Canal filled with iRoot SP. Fig. 21_Canal filled with BioAggregate.
mation of chemical bond with dentin, insolubility in
tissue fluids, expansion during time of set, very good
radiopacity, easy handling are the features that make
bioceramic-based sealers an up-to-date alternative
to current “golden” standard of multi-phase (gutta-
percha — epoxy sealer) warm techniques.
Thanks to its very good features, iRoot SP is cur-
rently probably the best product to be used with
“capillary condensation” technique for “endodontic
grafting” of apical third and for hermetic sealing of
complex root canals space.
Aknowledgments
Scanning electron microscopy has been kindly of-
fered for use in this article by IBC — Canada. It is the
property of INNOVATIVE BIOCERAMIX.
The authors would like to express their thankful-
ness to Marlena Tchimpilska, Medical Library, Medical
University of Pleven, for help with literature search;
Vesselin Nedelcev for preparation of polarisation
microscopy samples; and to Elena Stoyanova, dental
assistant.
_About the authors roots
Dr. Deyan Kossev
Dr. Deyan Kossev graduated from the Dental Faculty of Medical University
of Plovdiv in 1991. Between 1991 and 1995 he practiced as a GP, and
between 1995 and 2001 as a staff member of Oral Surgery Department of
Municipal Dental Clinic, Kazanlik. Since 2002 he has been working exclu-
sively in private practice, specializing in endodontics, restorative dentistry
and implantology. Kossev may be contacted at drkosev@gmail.com.
Dr. Valeri Stefanov
Dr. Valeri Stefanov graduated from the Dental Faculty of Medical Academy
of Sofia in 1982. He practiced as a GP from 1982 to 1986 at the Dentistry
Department of Municipal Hospital of Levski. Between 1986 and 1992 he
practiced as an oral surgeon at OMS Department of Municipal Hospital of
Pleven. Since 1993 he has been exclusively in private practice, specializing
in oral surgery, implantology, endodontics and restorative dentistry. In 1990
Stefanov was awarded the Leibinger Prize for extraordinary contribution to
the specialty of OMFS by the European Association of Cranio-Maxillo-Facial
Surgery. He is an honorary member and diplomate of the German Society
for Implant Dentistry (DGZI). He has been a member of Editorial Board of
IJOMFS. He is founder and former president of the Bulgarian Society of Oral
Implantology and Biomaterials. He lectures nationally and internationally.
Stefanov may be contacted at stefanov.valeri@abv.bg.
roots
1 _ 2009 I 47
3/5/09 11:55:34 AM
 I research _ ceramics-based sealers
References:
1. Bergenholz, G. et al. Controversies in Endodontics / G. Ber-
genholz, L. Spangberg. // Crit. Rev. Oral Biol. Med, 15, 2004,
2 : 99–114.
2. Bodrumlu, E. et al. Apical leakage of Resilon obturation material
/ E. Bodrumlu, U. Tunga. // J. Contemp. Dent. Pract., 7, 2006, 4
: 45–52.
3. Cantatore, G. Obturation canalaire et preservation radiculaire /
G. Cantatore. // Realites Cliniques, 15, 2004, 1 : 33–53.
4. Gohring, K.S. Indications for use of MTA, a review. Part 1: Chemi-
cal, physical and biological properties of MTA / K.S. Gohring, B.
Lehnert, M. Zehnder. // Schweiz. Monatsschr. Zahnmed., 114,
2004, 2 :143–53.
5. Maltezos, C. et al. Comparison of the sealing of Resilon, Pro Root
MTA, and Super-EBA as root-end filling materials: a bacterial
leakage study / C. Maltezos, G.N. Glickman, P. Ezzo, J. He. // J.
Endod., 32, 2006, 4 :324–327.
6. Rafter, M. Apexification: a review / Mary Rafter // Dental Trau-
I industry report_ VDW
An ultrasonic device with
focus on endodontics
A
The VDW.ULTRA ultrasonic device
enhances endodontic treatment. n ultrasonic device in endodontics — why is
it necessary? It is a fact that today’s endo-
dontists can no longer think of endodontic
treatments without ultrasound, not because they
want high standard equipment, but because they
know about the essential advantages the ultrasonic
technique provides for their endodontic treatments.
The increasing demand comes mostly from practices
that are either interested or specializing in endodon-
tics. For this reason VDW, the expert in endodontics,
has developed an ultrasonic device especially for root
canal treatment: the VDW.ULTRA®.
The main function of this device surely is the
activation of irrigation: vibrations create air bubbles
48 I roots 1_ 2009
RO0109_1-52.indd 48
matology, 21, 2005, 1 : 1–8.
7. Ricucci D. et al. Apical limit of root canal instrumentation and
obturation : Part 2. A histological Study / D. Ricucci, K. Langeland.
// Int. Endod. Journal, 31, 1998: 394–409.
8. Tay, F.R. et al. Suseptibility of a polycaprolactone based root ca-
nal filling material to degradation. I. Alkaline Hydrolysis / F.R. Tay,
D.H. Pashley, M.C. Williams, R. Raina, R.J. Loushine, R.N. Weller,
W.F. Kimbrough, N.M. King. // J. Endod., 31, 2005 : 593–598.
9. Tay, F.R. et al. Susceptibility of a polycaprolactone-based root
canal filling material to degradation. II. Gravimetric evaluation
of enzymatic hydrolysis / F.R. Tay, D.H. Pashley, C.K. Yiu, J.Y. Yau,
M. Yiu-fai, R.J. Loushine, R.N. Weller, W.F. Kimbrough, N.M. King.
// J. Endod., 31, 2005, 10 : 737–41.
10. Verissimo, D.M. et al. Comparison of Apical Leakage between
Canals Filled with Gutta-Percha/AH-Plus and the Resilon/
Epiphany System, When Submitted to Two Filling Techniques /
D.M. Verissimo, M. Sampaio do Vale, A.J. Monteiro. // J. Endod.,
33, 2007, 3 :291–294.
in the irrigation solution, they implode immediately
and remove tissue and bio film. They reach into dentin
tubules and lateral canals and reduce significantly
the infection risk. As mere mechanical preparation
reaches only about 70 percent of these areas, inten-
sive irrigation is crucial for eliminating bacteria. A
new feature is the passive ultrasonic irrigation with
special instruments avoiding unwanted filing in the
irrigation phase.
Additional functions, such as fine-preparation of
the access cavity, retreatment, as well as removal of
metal posts and fractured instruments, are available.
The handy device provides high comfort treatments.
Thanks to the patented “auto-balance-system” en-
suring reliable automatic regulation, the VDW.ULTRA
is able to deliver a constant and efficient performance
for every application. The piezo-electric handpiece
weighs only 50g and can be sterilized in the autoclave.
Also classic periodontal and scaling applications can
be carried out efficiently.
VDW provides a high-quality tailor-made tip
assortment for use in endodontics: irrigation files
for thorough ultrasonic cleaning and the removal
of bio film, diamond-coated tips for efficient fine-
preparation of the access cavity, fine tips made of
the novel (innovative) titanium-niobium alloy for
delicate retreatments, as well as a robust tip to remove
metal posts with high intensity.
For more information, visit VDW online at www.
vdw-dental.com.
3/5/09 11:55:35 AM

submissions:
formatting requirements
_Please note that all the textual elements of
your submission:
_the complete article,
_all the figure captions,
_the complete literature list, and
_the contact info (bio, mailing address,
E-mail address, etc.)
must be combined into one Word document.
Please do not submit multiple files for each
of these items.
In addition, images (tables, charts, photo-
graphs, etc.) must not be embedded into the
Word document. All images must be submit-
ted separately, and details about how to do
this appear below.
Text length
Article lengths can vary greatly—from a
mere 1,500 to 5,500 words—depending on
the subject matter. Our approach is that if
you need more or less words to do the topic
justice then please make the article as long or
as short as necessary.
We can run an extra long article in multiple
parts, but this is usually discussing a subject
matter where each part can stand alone
because it contains so much information.
In addition, we do run multi-part series on
various topics.
In short, we do not want to limit you in terms
of article length, so please use the word
count above as a general guideline and if
you have specific questions, please do not
hesitate to contact us.
Text formatting
Please use single spacing and un-indented
paragraphs for your text. Just place an extra
blank line between paragraphs.
We also ask that you forego any special
formatting beyond the use of italics and
boldface, and make sure that all text is left
justified.
RO0109_1-52.indd 49
about the publisher _ submissions
If you would like to emphasize certain words
within the text, please only use italics (do not
use underlining or a larger font size). Bold-
face is reserved for article headers.
Please do not “center” text on the page, add
special tab stops, or use underling as all of
this must be removed before layout. If you
require a special layout, please let the word
processing program you are using help you
to do this formatting rather than doing it by
hand on your own.
If you need to make a list, or add footnotes
or endnotes, please let the Word processing
program do it for you automatically. There
are menus in every program that will help
you to do this. The fact is that no matter how
careful one might be, errors have a way of
creeping in when you try to hand number
footnotes and literature lists.
Image requirements
Please number images consecutively
throughout the article by using a new
number for each image. If it is imperative
that certain images are grouped together,
then use lowercase letters to designate the
images in a group (ie, 2a, 2b, 2c).
Please put figure references in your article
wherever they are appropriate, whether that
is in the middle or end of a sentence. If you
are not directly mentioning the figure in the
body of your article, when it appears at the
end of the sentence the figure reference
should be enclosed within parenthesis and
be inside the sentence, meaning before the
period.
In addition, please note:
_We require images in TIF or JPEG format.
_These images must be no smaller than
6 x 6 cm in size at 300 DPI.
_Images cannot be any smaller than 80 KB in
size (or they will print the size of a postage
stamp!).
Larger images are always better, and some-
thing on the order of 1 MB is best. Thus, if
you have an image in a large size, do not
bother sizing it down to meet our require-
I
ments but send us the largest file sizes
available. (The larger the starting image
is in terms of bytes, the more leeway the
designer has in terms of resizing the image
to fill up more space should there be room
available).
Also, please remember that you should
not embed the images into the body of
the text document you submit. Images
must be submitted separately from the
textual submission.
You may submit images through a zipped
file via E-mail, unzipped individual files
via E-mail, or post a CD containing your
images directly to us (please contact
us for the mailing address as this will
depend upon where in the world you will
be mailing them from).
Please do not forget to send us a head
shot photo of yourself that also fits
the parameters above so that it can be
printed along with your article.
Abstracts
An abstract of your article is not re-
quired. However, if you choose to pro-
vide us with one, we will print it in a
separate box.
Contact info
At the end of every article is a Contact Info
box with contact information along with
a head shot of the author. Please note at
the end of your article the exact informa-
tion you would like to appear in this box
and format it according to the previously
mentioned standards. A short bio may
precede the contact info if you provide
us with the necessary information (60
words or less).
Questions?
Please contact us for our Author Kit, or if you
have other questions:
Managing Editor
Fred Michmershuizen
f.michmershuizen@dtamerica.com
roots
1 _ 2009 I 49
3/5/09 11:58:13 AM
 I about the publisher _ imprint

roots
the international magazine of endodontics

Publisher International Offices Editorial Board Members

Torsten R. Oemus Fernando Goldberg, Argentina
t.oemus@dtamerica.com Europe Markus Haapasalo, Canada
Dental Tribune International GmbH Ken Serota, Canada
President Contact: Daniela Zierke Clemens Bargholz, Germany
Peter Witteczek Holbeinstr. 29 Michael Baumann, Germany
p.witteczek@dtamerica.com 04229 Leipzig, Germany Benjamin Briseno, Germany
Phone: +49-341-48474-302 Asgeir Sigurdsson, Iceland
Chief Operating Officer Fax: +49-341-48474-173 Adam Stabholz, Israel
Eric Seid www.dti-publishing.com Heike Steffen, Germany
e.seid@dtamerica.com Gary Cheung, Hong Kong
Asia Pacific Unni Endal, Norway
Group Editor Dental Tribune Asia Pacific Ltd. Roman Borczyk, Poland
Robin Goodman Contact: Tony Lo Bartosz Cerkaski, Poland
r.goodman@dtamerica.com Room 1602, 108 Java Road Esteban Brau, Spain
North Point, Hong Kong José Pumarola, Spain
Editor in Chief Phone: +852-3118 7508 Kishor Gulabivala, United Kingdom
Karl Behr Fax: +852-3118 7509 William P. Saunders, United Kingdom
k.behr@dental-tribune.com www.dti-publishing.com Fred Barnett, U.S.A.
L. Stephan Buchanan, U.S.A.
Managing Editor Jo Dovgan, U.S.A.
Fred Michmershuizen The Americas Vladimir Gorokhovsky, U.S.A.
f.michmershuizen@dtamerica.com Dental Tribune America, LLC James Gutmann, U.S.A.
Contact: Anna Wlodarczyk Ben Johnson, U.S.A.
Art Director 213 West 35th Street, Suite 801 Kenneth Koch, U.S.A.
Yodit Tesfaye Walker New York, NY 10001 Sergio Kuttler, U.S.A.
y.tesfaye@dtamerica.com Tel.: +1 (212) 244-7181 John Nusstein, U.S.A.
Fax: +1 (212) 244-7185 Ove Peters, U.S.A.
Marketing Manager www.dti-publishing.com Jorge Vera, Mexico
Anna Wlodarczyk-Kataoka
a.wlodarczyk@dtamerica.com

International Administration
President/CEO
Torsten R. Oemus
t.oemus@dtamerica.com

Executive Vice President

Finance
Dan Wunderlich
d.wunderlich@dental-tribune.com

roots_Copyright Regulations 
_the international magazine of endodontics is published by Dental Tribune America LLC and will appear in 2009 with one issue every quarter.
The magazine and all articles and illustrations therein are protected by copyright. Any utilization without the prior consent of editor and
publisher is inadmissible and liable to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and
processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any
submissions to the editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial
department reserves the right to check all submitted articles for formal errors and factual authority, and to make amendments if necessary.
No responsibility shall be taken for unsolicited books and manuscripts. Articles bearing symbols other than that of the editorial department,
or which are distinguished by the name of the author, represent the opinion of the afore-mentioned, and do not have to comply with the
views of Dental Tribune America LLC. Responsibility for such articles shall be borne by the author. Responsibility for advertisements and other
specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for information published
about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation
are excluded. General terms and conditions apply, legal venue is New York, NY, U.S.A.

50 I roots 1_ 2009

RO0109_1-52.indd 50 3/5/09 12:13:48 PM

Order_Form_web 02.03.2009 13:19 Uhr Seite 1

Dental Tribune International GmbH | Contact: Nadine Parczyk

Holbeinstraße 29 | 04229 Leipzig | Germany
Tel.: +49 341 484 74 330 | Fax: +49 341 484 74 173
n.parczyk@dental-tribune.com | www.dental-tribune.com

❏ I hereby order 4 issues of COSMETIC

DENTISTRY for 35 € (1 year)* ❏ I hereby order 20 issues of DENTAL TRIBUNE
GERMAN EDITION for 70 € (1 year)* ❏ I hereby order 10 issues of DENTAL TRIBUNE
AUSTRIAN EDITION for 55 € (1 year)*

❏ I hereby order 4 issues of ROOTS

for 35 € (1 year)* ❏ I hereby order 10 issues of DENTAL TRIBUNE
ASIA PACIFIC EDITION for 55 € (1 year)*

PAYMENT OPTIONS PERSONAL DETAILS/SHIPPING ADDRESS

❏ PayPal Name
subscriptions@dental-tribune.com Position

❏ Bank Transfer Department

Organisation
Commerzbank Leipzig
Account No.: 11 40 201 Address

Bank Code: 860 400 00 Country

BIC: COBADEFF Telephone
IBAN: DE57860400000114020100 Facsimile
E-mail
*plus shipping and handling. Your personal data will be recorded and retained by Dental Tribune
International GmbH, which has its registered office in Holbeinstr. 29, 04229 Leipzig, Germany. Your
personal data is used for internal purposes only. After the payment has been made, the shipping pro-
cess for the subscribed publication(s) will start. The subscription will be renewed automatically every
year until it is cancelled six weeks in advance to the renewal date. Date/Signature

Fax form to: +49 341 484 74 173 or subscribe online at www.dental-tribune.com
Anschnitt DIN A4 06.03.2009 12:05 Uhr Seite 1

TOOLS TO KEEP SMILING

/ N . 5 8
a l l 1 0 . 2
ID S - H
Rotary NiTi instruments

FKG RaCe
NON-CUTTING SAFETY TIP
• Perfect control of the instrument

NON-THREADING DESIGN
• Alternating cutting edges

IMPROVED EFFICIENCY
• Sharp cutting edges

ELECTRO-CHEMICAL TREATMENT
• Better resistance to torsion and metal fatigue

FOR MASTERING METAL FATIGUE

• SafetyMemoDisc

2 optimised sequences within

one set of instruments for Crown-
Down or Single-Length technics

Try it on FKG stand!

Crêt-du-Locle 4 • CH-2304 La Chaux-de-Fonds - Switzerland • Tél.: +41 (0)32 924 22 44 • Fax: +41 (0)32 924 22 55 • info@fkg.ch • www.fkg.ch