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A Clinically Relevant Review of Nickel Titanium Canal Enlargement
A Peer-Reviewed Publication Written by Richard E. Mounce, DDS
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and offer different physical properties to traditional ground RNT. Regardless of the method and technique selected. findings). Be knowledgeable about the factors involved in successful endodontic therapy. Poor obturation Introduction Endodontic treatment has evolved greatly over the last two decades with the introduction of new canal preparation systems. they can be more or less efficient and more or less resistant to breakage. The goal of endodontic treatment is the three dimensional cleansing. and today RNT methods predominate in the developed world and among specialists. RNT files are available as traditional ground nickel titanium files and as twisted files (TF). Figure 2. with resolution of any infection and complete healing of periapical tissues (if these presented with pathological 2 Goals of endodontic cleansing and shaping The goal of endodontic treatment is the three-dimensional cleansing. found that properly prepared teeth that were free of bacteria prior to obturation had a five-year success rate of 94% compared to 68% for teeth that remained contaminated. systematic and safe when used appropriately. File fracture can be the result of the properties of the alloy itself. The use of RNT has enabled more centered canal preparations and fewer canal aberrations during preparation compared to previous techniques. Endodontic treatment has a high success rate when performed appropriately. The ultimate goal is long-term retention of the tooth restored with a competent coronal seal and final restoration.Educational Objectives Upon completion of this course. Depending on the design of RNT files. Irrigants flow into the spaces cleared by instruments and provide asepsis to the greatest www.com . Endodontically-treated tooth with good obturation and seals Abstract Endodontic treatment has evolved greatly over the last two decades and has a high success rate when performed apropriately. Know the factors involved in safely performing endodontic therapy and how to minimize file fracture occurrence. shaping. and/or the clinician’s technique. the clinician must use an appropriate technique and great care when performing endodontic procedures. Rotary nickel titanium (RNT) files became commercially available in the early 1990s for canal enlargement. 4. 2. TF are the first RNT that can be efficiently and safely used as a single file technique.1. 3.2.6 In the most general terms. and is efficient. obturation materials.ineedce.5. and 74%–86% if apical periodontitis was present. the instruments that shape the canal provide a gross debridement. Sjogren et al. Canal instrumentation by hand was the first technique to be implemented and is still used today. The success rate has been found to be 91%–98% in separate studies on teeth with no periapical periodontitis at the time of endodontic therapy. Understand the types of instrumentation methods and their attributes for canal shaping and cleaning. and obturation of the canal space from the canal orifice to the minor constriction of the apical foramen. The mechanical shaping of root canal systems has been accomplished with a wide variety of methods and instruments. irrigation methods.4 Figure 1. It is generally considered that the single most important success factor in endodontic treatment is root canal preparation — the cleansing and shaping of the root canals prior to obturation. and visualization aids such as dental microscopes.3 It is generally considered that the single most important success factor in endodontic treatment is root canal preparation — the cleansing and shaping of root canals prior to obturation. the clinician will be able to do the following: 1. and obturation of the canal space from the canal orifice to the minor constriction of the apical foramen. Know the methods of manufacturing rotary nickel titanium files and understand the resulting physical differences. shaping.

3.ineedce. The quality of microbial control.19. heating.14 The effectiveness of irrigation and the resulting canal cleanliness (and ultimately clinical success) are dependent primarily on the following factors: 1.com Canal instrumentation by hand was the first technique to be implemented and is still used today. reamers. maintains the minor constriction of the apical foramen at its original position and size. dissolve residual tissue.9 Chlorhexidine gluconate is an effective irrigant capable of killing and eliminating highly pathogenic intra-canal microbes (E. has a narrowing cross-sectional diameter of an appropriate taper. faecalis from root canals. Instrumentation methods Mechanical cleaning and shaping of canals The mechanical shaping of root canal systems has been accomplished with a wide variety of methods and instruments (Figure 3). chlorhexidine gluconate. there is no universally agreed upon or scientifically proven irrigation and instrumentation regimen that provides a predictably bacteria-free canal after endodontic canal preparation. 2. Endodontic treatment that is followed by an excellent coronal seal prevents the apical migration of bacteria after treatment that would predictably occur if the obturation were not protected.13.18.17. and facilitates efficient irrigation for canal cleanliness and optimal hydraulic forces during obturation. Hedstrom files. a negative experience with RNT files (file breakage). Ultrasonic activation has also been used for canal debridement. Clinicians may favor this technique as a result of having learned this technique first.15. Clinical success is improved by a preparation that maintains the canal in its original position. as well as other canal instruments (using a handpiece attachment that reciprocates a hand file 30 degree clockwise and 30 degrees counterclockwise) 3. the frequency of the exchange. Irrigation is optimized by using the correct solution for the type of tissue in the canal (necrotic or vital). studies have found that EDTA and NaOCl are ineffective in eliminating E. Stainless steel hand files. Gates Glidden drills and Peezo Reamers (especially for coronal enlargement) 5. These techniques have included: www. the correct concentration. Rotary driven stainless steel instruments 6. Irrigants mechanically flush the area.8 However. and eliminate (kill) bacteria. and broaches 2. or for other reasons. a 5% concentration has been found to be more effective than lower concentrations. iodine potassium iodide. perceiving more tactile sensation and more accurate preparation. Rotary nickel titanium (RNT) files Figure 3. NaOCl is an effective microbicidal and effectively dissolves residual tissue. The quality of the coronal seal. It has been found to increase dentin permeability regardless of which irrigant was used with it11 and has also been found to result in increased residual antimicrobial activity. and activation (sonic and ultrasonic). Agents used for irrigation have included sodium hypochlorite (NaOCl). faecalis. Sonic and ultrasonic methods for canal enlargement and activation of irrigation 4.20 1.16. The quality of the canal preparation. A recent study found that rotary files created 3 .12 At this time. EDTA has been found to effectively remove the smear layer. and hydrogen peroxide. the correct volume. israelii)10 and is biocompatible. Reciprocating use of stainless steel hand files. depending on the study. reamers. among other factors. but it does not have the tissue dissolution capabilities of NaOCl. A. Hedstrom files.7 Care must be taken and an appropriate irrigation technique used to avoid extrusion of NaOCl through the apex to the periapical tissue and to avoid sodium hypochlorite accidents. EDTA.degree possible before obturation. Thorough irrigation using an effective irrigant is essential in reducing and eliminating bacterial contamination.

4% and found that the files could be used at least four times safely. in part due to the greater flexibility of nickel titanium and its resistance to stress. and RNT is generally used in a Crown Down technique.36. can occur suddenly.21 An ex vivo study investigating six manufacturers’ RNT files as well as hand files found that RNT instrumentation was more efficient.45 File fracture can be the result of the properties of the alloy itself.37. triangular and U shaped designs among others. Dentsply Tulsa Dental).29. etc.30 The use of RNT has enabled more centered canal preparations and fewer canal aberrations during preparation compared to previous techniques. The first rotary instruments to be introduced were manufactured from stainless steel. Taper of the file system. variable taper. number of flutes along the working length of the file) 3. Discus Dental. Efficient files cut very well. Cross-sectional design (symmetry or asymmetry. File tip (cutting. a review by Sequeira et al. especially in relation to the other methods available today and those used historically28.46 RNT files resistant to breakage may not have cut as easily as their efficient counterparts. among many different features: 1. Review of present systems available with regard to design features and clinical use RNT systems available today are quite diverse.32. Relative ease. found insufficient evidence for its effectiveness. followed by hand instrumentation to prepare the apical third of the canal. 4 Depending on the design of RNT files. both in their design configurations and suggested tactile uses.ineedce. File fracture Introduction to the use of nickel titanium in endodontic canal preparation (canal cleansing and shaping) Rotary nickel titanium (RNT) files became commercially available in the early 1990s for canal enlargement. however there can be a clinical perception that they cut well yet strip www. followed by nickel titanium instruments. and/or the clinician’s technique.43 Choosing one system over another is primarily empirical and dependent on clinician preference and the system on which the clinician was trained. and possibly both without warning and without previous deformation of the file (Figure 4). It has also been found that using a lateral brushing or pressing motion helps reduce the fatigue life of larger files.41. Many clinicians prefer RNT files over stainless steel files. MailleferDentsply) and stainless steel hand files found no statistically significant differences in tooth fractures. found that the reciprocating files removed more tooth structure in the coronal and middle third of the canals but there was no difference in tooth structure removal in the apical third.31 Using the Crown Down technique. fixed taper) 5. Variability of the helical angle (flute width.26 The introduction of rotary canal instruments significantly changed endodontics. the sequence of instrumentation is based on starting with larger files and using progressively smaller files. if it occurs. Grande et al.27 Now. the presence of a positive or negative rake angle and/ or cutting angle. regardless of manufacturer. they can be more or less efficient and more or less resistant to breakage.) 2. offering an efficient and systematic method of instrumentation.42.33.39. possible canal transportation.a better preparation than hand instrumentation. (no taper. or partially active) 4.22 An assessment of tooth fractures following the use of one of two types of RNT files (Lightspeed. there is no literature-based superiority of any given system relative to any other. having the following primary benefits: 1. File fracture is more likely to occur in files that have been used multiple times. Figure 4. File separation and fracture.com . and today RNT methods predominate.35. Predictability of the final canal shape 2. and cost. non cutting.44 A recent large cohort study on one RNT file (ProTaper) found a separation incidence of 2. with the size of the file influencing the number of uses.24 A recent study suggested a Crown Down technique with AET preparation of the coronal and middle thirds. flute depth. and resulted in fewer instrument fractures than hand instrumentation.23 In comparing reciprocating hand files (AET) with RNT (ProTaper.38. maintained the canal curvature. and safety in creating these shapes. although there was greater apical enlargement (Lightspeed) and increased canal taper (Greater Taper) with RNT instrumentation. The presence or absence of radial lands and whether the radial lands are relieved Concerns with regard to RNT methods primarily include file breakage.40.25 With respect to sonic and ultrasonic root canal preparation used alone for standard (orthograde) endodontic therapy. RNT file designs differ based on the following. Greater Taper. efficiency.34.

Beyond the elastic limit. CA.53. The absorption of greater force allows the RNT file to both negotiate curvatures and cut dentin at the same time safely and efficiently.com Figure 6.49 Both flexural failure and torsional failure can occur along microcracks that act as focus points and that are the result of the grinding of nickel titanium. with the exception of Lightspeed LSX (Discus Dental. Orange. and small files resist cyclic fatigue better than larger diameter files. When stressed during function. as long as the elastic limit of the metal is not exceeded. grooves.54 Twisting Manufacturing nickel titanium files by twisting results in a file formed from one piece of nickel titanium. while simultaneously dulling the cutting edges. The transformation between the two phases has also been found to vary with RNT from different manufacturers. and break. have been introduced to minimize the effects of microcracks. and apical transportation and the potential for breakage are concerns. Culver City. how much friction the file encounters as it rotates. Torsional fracture resistance is a function of rotational speed. i. Twisted rotary nickel titanium file (TF) 5 . the file will eventually reach its plastic limit. If excessive force or deformation occurs during use.48 and when stressed during canal enlargement undergoes a molecular phase transformation. it undergoes a transformation to the martensite crystalline structure that can absorb a higher force than non-shape memory alloys.e. the manner in which the file is used. In its resting state (in the form of a nickel titanium file) it has an austenite crystalline structure. Additionally. All existing RNT files on the global market at this time are ground from nickel titanium wire. and the method of manufacturing. cutting efficiency of the file. CA. Electropolishing mitigates the effects of grinding and reduces surface defects such as microcracks. An additional difference with Lightspeed LSX is that while other systems use tapered files. the handle of the file is not a second piece of metal attached to the nickel titanium file shaft. degree of flute engagement against the dentin walls. It is important that the clinician use an appropriate technique when using the files. and will return to its original shape. Fracture is a result of either excessive torsional forces or flexural failure (cyclic fatigue failure). USA) is manufactured by twisting the nickel titanium instead of grinding it. Flexural failure is a result of the tension experienced on one side of an RNT file and the compression experienced on the other side as the file rotates in the canal. Focus points that concentrate stress also occur as a result of acute www. The cutting flutes of twisted files (TF) are not created by grinding and the grain structure of nickel titanium is never cut across. Ground rotary nickel titanium file Methods of rotary nickel titanium endodontic instrument manufacture Grinding Nickel titanium is a shape memory alloy that is superelastic47. It is a combination of these two modes of failure results in RNT separation and file fracture. USA). changes in file design and geometry. and metal rollover. the Lightspeed uses a design that although similar to a Gates-Glidden file is different. files can exceed their elastic and plastic limits. resulting in different properties.51.. such as electropolishing. (Figures 5.perforation. A newly introduced Twisted File (TF) (SybronEndo. 52 Large diameter files resist torsion better than smaller diameter files. RNT safety and efficiency are collectively determined by the design of the file. which will increase resistance to fracture. 6) Figure 5.50 Various surface finishes. The elastic limit of the metal is the maximum amount of deformation that a file can withstand and yet still return to its original shape. Cheung and Darvall recently found that the cross-sectional shape of RNT does not influence low cyclic fatigue.ineedce. and the ease of channeling debris out of the canal inherent in the file design and tactile use. maintaining its integrity. Recent studies have found that electropolishing improves resistance to cyclic fatigue and torsional loading.

a . compared to traditional methods. on average 4 mm or more of canal wall will have been cut.08 TF will almost certainly be able to reach the apex. For a single-file technique. and pitch. For smaller and highly curved canals. By the time the clinician feels tactile resistance and withdraws TF. fracture of TF will be greatly reduced. the Crown Down technique is used. For open. for a two-file technique. and . TF samples were able to withstand about 60% more torque than the other samples. If used as a two. Independent laboratory testing of twisted nickel titanium files has found that55: “the microstructure of the TF material is finer than the corresponding ones for the traditional manufacturing process. with more than a 100% increase compared to ground file samples. flute width.08 or . frequent recapitulation. the clinician can usually reach the apex in 3 TF insertions.” TF resisted torsional failure and absorbed the greatest amount of energy before fracture.12 tapers into the apical third and do it safely and efficiently. the . 6 individual TF placements into the canal are typically needed. Engagement of the file should be minimized. For more intermediate sized canals.10. having used TF extensively in all manner of clinical anatomy as a FT endodontist (Figures 7–9). TF can provide flexibility and resist fracture due to cyclic fatigue and torsional failure and if used per the manufacturer’s recommendations. the TF has a triangular cross section that makes it extremely flexible and has a variable helical angle. As a result of the twisting. In my experience.or three-file technique.”56 It can be concluded from the results of in vitro testing that the twisted file (TF) may offer clinicians a safer means by which to clean and shape root canal systems.Twisted nickel titanium files are created by taking the raw nickel titanium wire in the austenite crystalline structure and transforming it into a different phase of crystalline structure (R-phase) by a process of heating and cooling. if the clinician used a . the . but it can be twisted. depth. . Once twisted. and is inserted until resistance is felt and the file withdrawn. patent.08. the file is heated and cooled again to maintain its new shape and convert it back into the austenite crystalline structure which is superelastic once stressed (and can be used in endodontic function). nickel titanium cannot be ground. cian may do so any way desired. and large canals such as the palatal canal of upper molars. if the correct taper is initially chosen. The file then receives a final chemical surface treatment of deoxidation that maintains the surface hardness of the metal without reducing the sharpness of cutting flutes or reducing the hardness of the metal. TF can be used in many canals as a single file instrument that can create .10 TF can often be taken to the working length (TWL) of the preparation as well as being the first file used in the canal. If the clinician wishes to create a larger apical diameter then a 25 (the maximum available TF tip size).06 TF can often be taken to the TWL of the preparation as well as being the first file used in the canal. Clinical Cases treated with a single TF file (. It was also found that the twisting manufacturing process significantly increased number of cycles to failure and bending energy to failure. achievement of continuous taper is simple if the clinician will build into the preparation design the concept that the initial TF file used at the orifice can be taken to the apex of the root. In other words. the clini6 www.com . straight.10 or .10 TF as the initial file at the orifice. As with other systems. Since TF is a fixed tip size instrument and only varies in its taper. including mildly curved and slightly shorter roots (bicuspids) the . care must be taken to select the appropriate size file to avoid excessive removal of dentin (as occurs if using files that are too large). Clinical application Clinically. TF is rotated at 500 rpm and used in the presence of copious irrigation. TF is recommended for use in a single tooth and to then be discarded. In R-phase. Figure 7. TF use should be preceded by the use of hand files to manually preflare the canal to the minimal diameter of a #15 hand K file. and if not.ineedce.” “…files from the new TF manufacturing method result in a significantly higher average hardness.12 or . a gentle and passive touch.08 TF can often be taken to the TWL of the preparation as well as being the first file used in the canal.” “TF final products absorb 500% respectively more bending energy than other samples. it generally can be taken to the apex.10).

Phase II: initial treatment. pastes.30:297–306. Guerrero A.16(10):498–504. de Oliveira EP. 3 Friedman S. Evaluation of ethylenediaminetetraacetic acid (EDTA) solution and gel for smear layer removal. Retreatment. 7 Baratto-Filho F. 2 Farzaneh M.57 Summary Endodontic treatment has evolved greatly over the last two decades with the introduction of new canal preparation systems. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. rotary files. and warm carrier-based devices. regardless of the type of file used. Aust Endod J. 2003.com . irrigation methods. and sonic and ultrasonic instrumentation. Miller GA. et al.137(1):67–70. Future developments may result in methods of manufacture for nickel titanium other than grinding and twisting. Hilmioglu S. Ribeiro de Carvalho Jr. It should be noted that both RNT ground files and TF can be used with any currently available electric endodonwww. used Crown Down (.15(6):348–81. Figdor D. Sundqvist G.20(3):164–8.15:1. et al. J Am Dent Assoc. such as casting. Braz Dent J. Treatment outcome in endodontics—the Toronto Study. Evid Based Dent. Better success rate for root canal therapy when treatment includes obturation short of the apex. 4 Sjogren U. but these uses will require higher rpm. Dent Traumatol. 2005. or forcing a cutting edge into a metal (as barbed broaches are now constructed). J Endod.12. Hagglund B. Wing K. 2007. Clinical case treated with three TF files used Crown Down (. J Endod.6(2):45.10 TF). 2006. and obturation materials. Friedman S. Pécora JD. 2004. Int Endod J. 9 Jha D. both types of files can be used to remove gutta-percha. Machado ME. The effect of passive ultrasonic activation of 2% chlorhexidine or 5. Comparison of antibacterial and toxic effects of various root canal irrigants.30(5):302–9. 1990. Helfer A. TF are the first RNT files that can be efficiently and safely used as a single file technique.08 TF). RNT files are available as traditional ground nickel titanium files and as twisted files (TF). Lawrence HP. 6 Nair PN. 10 Oncag O. Ngo T. Eronat C.10 TF). J Endod. 7 Figure 8b. Clinical case treated with two TF files. offering predictability of the final canal shape. 1997. electrical discharge machining (EDM). Zekioglu O. 5 Naito T.10 and . 2003..33(2):62–5. Crit Rev Oral Biol Med. Toronto Study.32(6):493–503. Travassos RM. Inability of laser and rotary instrumentation to eliminate root canal infection. Diener-West M. In vitro assessment of dentinal permeability after the use of ultrasonic-activated irrigants in the pulp chamber before internal dental bleaching. RNT methods currently predominate. 2004. References Figure 9. . 8 Dotto SR. Regardless of the method selected. Abitbol S.ineedce. Fröner IC. Johnson JD. Int Endod J.12 and . Martins JL.12 and . Persson S. Clinical case treated with two TF files. Factors affecting the long-term results of endodontic treatment. Hosgor M. Sousa-Neto MD.29(9):562–4. 11 Carrasco LD. It is unclear at this time whether these methods could provide any advantages over current manufacturing. efficiency. In addition. and offer different physical properties than traditional ground RNT files. McClanahan SB. The success of endodontic therapy—healing and functionality. Sundqvist G. tic motor.36(6):423–32.25% sodium hypochlorite irrigant on residual antimicrobial activity in root canals. Pathogenesis of apical periodontitis and the causes of endodontic failures. 1 Sjögren U. Canal preparation methods include hand files. Hasselgren G. 2004. Morphometric analysis of the effectiveness of different concentrations of sodium hypochlorite associated with rotary instrumentation for root canal cleaning. Pécora JD. and safety. Fariniuk LF. 2004. relative ease of use. the clinician must use an appropriate technique and great care when performing endodontic procedures. 2004. 12 Weber CD. J Calif Dent Assoc. used Crown Down (.Figure 8a. is most often a specialist procedure—caution and clinical judgment are advised. Mor C.

Int Endod J. 22 Guelzow A. Rôças IN. Butti A. 2001. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 33 Schirrmeister JF. 30 Brkanic T. 43 Low D.40(8):626–32. Cross-sectional analysis of root canals prepared with NiTi rotary instruments and stainless steel reciprocating files. Pameijer CH. 2007. Physical and mechanical characterization and the influence of cyclic loading on the behaviour of nickel-titanium wires employed in the manufacture of rotary endodontic instruments. Mechanical root canal preparation with NiTi rotary instruments: rationale. Chattanooga. 20 Swartz DB.(4):CD006384. Twenty years of endodontic success and failure. Int Endod J. 2007.100(2):249–55. For your convenience. Reader Feedback We encourage your comments on this or any PennWell course. Decrease in the fatigue resistance of nickel-titanium rotary instruments after clinical use in curved root canals. Hellwig E. Int Endod J. Separation incidence of protaper rotary instruments: a large cohort clinical evaluation. 2006. He is in private practice in Endodontics in Vancouver.32(7):675–9.33(5):541–7.4:346–51. 2007.dentaleconomics. Sorci E.101(6):807–13. Dasanayake AP. Torsional properties of new and used rotary K3 NiTi files. Anatomic Endodontic Technology (AET)—a crown-down root canal preparation technique: basic concepts. Influence of a brushing working motion on the fatigue life of NiTi rotary instruments. Wrbas KT. 1995. Melo MC. Decrease in the fatigue resistance of nickel-titanium rotary instruments after clinical use in curved root canals. Buono VT. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Int Endod J. Johnson WT.37(10):811–7. 25 Riitano F. Available at: http://mrsec. Eliopoulos D. Mathematical modeling of flexural behavior of rotary nickel-titanium endodontic instruments. Nasser M. 40 Loizides A. J Endod. 51 Anderson ME. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Messer HH. 54 Yared G. J Endod. Buono VT.31(7):529–32. Assessment of leakage in the restored pulp chamber of endodontically treated multirooted teeth. 41 Bahia MG. Lambrechts P. 1997.ineedce. Oral Surg 1997. Am J Dent. Quintessence Int. Mounce. Kettering JD. 2006. Ho AW. Author Profile Richard E.04 in simulated curved root canals prepared by students. 1990. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.com. Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. 39 Bahia MG.16(12):566–9. 2006. Buono VT. Drake DR. Azevedo RB. operative procedure and instruments. WA. J Endod. Cheung GS. 23 Lam PP.32(6):545–8. Comparison of defects in ProFile and ProTaper systems after clinical use.com. Kulkarni GK. html. 53 Pruett JP. 29 Peters OA. Ultrasonic versus hand instrumentation for orthograde root canal treatment of permanent teeth.com . J Endod. 2004. Cyclic fatigue testing of nickel-titanium endodontic instruments. Atomic force microscopy study of stainless-steel and nickel-titanium files. Silva LP. Aust Endod J.9:198–202. 2006. Gonzalez BM.38(8):575–87. 2006.13 Siqueira JF Jr. J Endod. 2006. Root canal preparation techniques using nickel-titanium rotary instruments.84:310–4.29(2):75–8. Root canal transportation with a Ni-Ti rotary file system and stainless steel hand files in simulated root canals. Neofitou C. 17 Torabinejad M. Saunders EM.100(2):249–55. Kielbassa AM. Messer HH. Kontakiotis E.39(1):48–54. 52 Tripi TR. Comparison of K hand files and ProFiles 0. J Endod.edu/Edetc/background/memmetal/index. Int Endod J.wikipedia.06/0.org/wiki/Shape_memory_ alloy#Applications. 2005. Accessed February 6. Trope M. 2005. Int Endod J. Polychroniadis EK. Peters CI. Walton RE. Peng B.102(4):e106–14. Current challenges and concepts in the preparation of root canal systems: a review. Price JW.30(8):559–67. 2005. 44 Bahia MG. J Endod. Johnson S. Comparative study of six rotary nickeltitanium systems and hand instrumentation for root canal preparation. 32 Alexandrou GB. Van Cleynenbreugel J. Influence of phase transformation on the torsional and bending properties of nickel-titanium rotary endodontic instruments. Hayashi Y. Grande NM. Clement DJ. 34 Di Fiore PM. Lin L. TN. Rosin M. USA. Rôças IN. 36 Bahia MG. Economides N. Wevers M. Int Endod J. Darvell BW. 2004.58(3–4):203–7. 2003. Martins RC. 1983. Lambrianidis T.com. Gerstein H. Carnes DL Jr. Vasiliadis LP.103(1):120–6. 2005. Rotary NiTi instrument fracture and its consequences.101(5):675–80.39(6):502–9. Fracture resistance of electropolished rotary nickeltitanium endodontic instruments. Somma F. An evaluation of microbial coronal leakage in the restored pulp chamber of root canal treated multirooted teeth. 27 Walia H. Low-cycle fatigue of NiTi rotary instruments of various crosssectional shapes. 35 Kosti E. 2007. J Endod. In vitro bacterial penetration of coronally unsealed endodontically treated teeth. Paiva SS. Reduction in the cultivable bacterial populations in infected root canals by a chlorhexidine-based antimicrobial protocol. Med Pregl. 1997. 2007 Oct 17.32(1):61–5. Somma F. Ghossayn F. Int Endod J. 48 Memory Metal. Darvell BW. Quintessence Int.31(12):882–5. 2007. Published by the Cloudland Institute. Zivkovic S. Welk A.40(1):45–51. 56 Ibid. Ebihara A. 28 Peters OA.14(5):324–33. 47 Shape memory alloy. Disclaimer The author has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.37(12):849–59. J Endod.38(10):743–52. 1990. 2007. Int Endod J. Suda H. 2006. 14 Siqueira JF Jr. Int Endod J. J Endod. Condorelli GG. An analysis of endodontic treatment with three nickeltitanium rotary root canal preparation techniques. Coronal leakage of mixed anaerobic bacteria after obturation and post space preparation. Minnich S. SEM observations and differential scanning calorimetric studies of new and sterilized nickel-titanium rotary endodontic instruments. He can be reached at RichardMounce@ MounceEndo. J Endod. Fracture of ProFile nickel-titanium rotary instruments: a laboratory simulation assessment. Plotino G. Accessed February 6. Bacterial reduction in infected root canals treated with 2. Barbakow F. 2005. 18 Saunders WP. 31 Bergmans L. 46 Plotino G. J Endod. Cochrane Database Syst Rev. 45 Wolcott S. Ishley D. Parashos P. 49 Parashos P. Kennedy W. 2008. Bian Z. an online feedback form is available at www. J Endod. 26 Sequeira P. 21 Steffen H. Shaping ability and safety of five different rotary nickel-titanium instruments compared with stainless steel hand instrumentation in simulated curved root canals. Palamara JE. Fracture strength of tooth roots following canal preparation by hand and rotary instrumentation. Pavlidou E. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Ung B.32(12):1139–41. Genov KI. 2005. Pedrazzi V. 42 Valois CR. 55 White Paper on Rotary Nickel Titanium Files. Stamm O. Yoneyama T. Cyclic fatigue of different nickel-titanium endodontic rotary instruments.23(1):28–33. Available at: http://en. Saunders EM. 2006.23(2):77–85. Mounce lectures globally and is widely published. Malagnino VA. Griffin JA. Martus P.28:12–18. Chrissafis K.33(10):1212–6. Strohl C. Drobac M. Buono VT.38(11):795–801. Skidmore AE. Saunders WP. 16 Barrieshi KM. Ex vivo study of the efficacy of H-files and rotary Ni-Ti instruments to remove gutta-percha and four types of sealer. 2008. 2005. J Endod. Löw A. 15 Ray HA. Doi H. 2006.33(6):667–72. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006. MacKenzie D. 1988. performance and safety. Status report for the American Journal of Dentistry. Komaroff E. An initial investigation of the bending and torsional properties of Nitinol root canal files. Wolcott J. Influence of simulated clinical use on the torsional behavior of nickel-titanium rotary endodontic instruments.5% NaOCl as an irrigant and calcium hydroxide/camphorated paramonochlorophenol paste as an intracanal dressing. Int Endod J.37(5):369–74. Available at www. 2006. 19 Chailertvanitkul P. 38 Miyai K. 57 Mastering Endodontic Instrumentation. 2005.ineedce. 24 Grande NM. Altenburger MJ. 2006. Meyers J. Bonaccorso A. 37 Shen Y. Magalhães KM. 8 www. Messina F.30(5):318–22. 50 Cheung GS. Fedorowicz Z. 2006.39(2):119–26. Int Endod J. 2007. Cheung GS. DDS Dr.32(11):1031–43. John McSpadden P 34.wisc. J Endod. Brantley WA.

dulls the cutting edges d. True b. cross-sectional design b. all of the above 10. a. a. a file formed from one piece of nickel titanium b. a and b 26. Irrigants used in endodontic therapy _________. no benefits over hand instrumentation c. with resolution of any infection and complete healing of periapical tissues. a. _________. the quality of the coronal seal c. 20. Canal instrumentation by hand was the first technique to be implemented and is still used today. a. Twisted nickel titanium files are created by taking the raw nickel titanium wire in the austenite crystalline structure and transforming it into a different phase of crystalline structure (R-phase). a. all of the above 24. Siqueira et al. a and b 21. file tip and taper d. Rotary files have been found to create a better preparation than does hand instrumentation. True b. The success rate of endodontic therapy has been found to be _________ in separate studies on teeth with no periapical periodontitis at the time of treatment. reciprocating files _________. TF is extremely flexible d. The cleansing and shaping of root canals prior to obturation is the least important component of endodontic therapy. a. False 25. a. a gross debridement d. dissolve residual tissue c. a. mechanically flush the area b. a. a. a. nickel titanium has a(n) _________ crystalline structure. a. False 9 www. finger rests d. Regardless of the method selected. a fine debridement c. the properties of the alloy itself b. RNT file designs differ based on _________. the early 1980s b. nickel titanium undergoes a molecular phase transformation. using the file too many times before discarding it d. martensite c. The instruments that shape the canal provide _________. File fracture is more likely to occur in files that have been used multiple times. 2. Grande et al. found that. 78%–87% d. a. and pitch c. 91%–98% a. False 9. False 13. Rotary nickel titanium (RNT) files became commercially available in _________. False 15. found sufficient evidence for the effectiveness of sonic and ultrasonic root canal preparation. superelastic c. True b. The Lightspeed RNT file uses a design that is identical to a GatesGlidden file. effectively dissolves residual tissue c.com . asepsis b. Concerns with regard to RNT methods include _________. all of the above 6. the early 1990s d. it undergoes a transformation to the _________ crystalline structure. Both RNT ground files and TF can be used with any currently available electric endodontic motor. False 29. False 11. The effectiveness of irrigation and the resulting canal cleanliness are dependent primarily on _________. at which time it can be twisted. a. all of the above 5. possible canal evulsion c. True b. none of the above 14. True b. File fracture can be the result of _________. a. a. a. file breakage b. 35%–45% b. TF has a triangular cross section b. the late 1990s 3. a and b 27. when stressed during function. the clinician’s technique c. More centered canal preparations and fewer canal aberrations during preparation are obtained using hand instrumentation rather than RNT files. martensite. True b. variability of the helical angle c. False 17. a. False 12. The ultimate goal of endodontic therapy is long-term retention of the tooth restored with a competent coronal seal and final restoration. TF has a variable helical angle. a. True b. the grain structure of nickel titanium maintaining its integrity d. a and c 8. True b. a. Manufacturing nickel titanium files by twisting results in _________. Electropolishing of RNT files _______. False 4. True b. a. There is no universally agreed upon or scientifically proven irrigation and instrumentation regimen. False a. all of the above 19. a. a. martensite. limited benefits over ultrasonic instrumentation d. True b. removed more tooth structure in the coronal third of the canals b. Sodium hypochlorite _________. removed more tooth structure in the apical third of the canals d. True b. False 7. a. False 18. all of the above 28. a. a. 55%–67% c. True b.ineedce. the quality of microbial control b. austenite. mitigates the effects of grinding b. a and c 23. As a result of twisting. can be used without any concern for its extrusion through the apex d. The introduction of rotary canal instruments offers _________. supermolecular d. When stressed during canal enlargement. depth. compared to RNT files. a shape memory alloy b. True b. a and b 30. eliminate (kill) bacteria d. Predictability of the final canal shape is an advantage offered by rotary nickel titanium files. Nickel titanium is _________. flute width. a file that will not bend c. False 22. the late 1980s c. reduces surface defects such as microcracks c. the clinician must use an appropriate technique and great care when performing endodontic procedures. a.Questions 1. helicosite d. austenite b. True b. is an effective microbicide b. an efficient and systematic method of instrumentation b. a. the quality of the canal preparation d. removed more tooth structure in the middle third of the canals c. all of the above 16. In its resting state (in the form of a file).

3) Complete answer sheets in either pen or pencil. Box 116. will be generated and mailed to you within five business days of receipt. How would you rate the objectives and educational methods? 5. which will list all credits earned to date. Know the methods of manufacturing rotary nickel titanium files and understand the resulting physical differences. Please rate your personal mastery of the course objectives. please complete the following: MC Visa AmEx Discover Acct. 2) Complete all information above. ___________________________________________________________________ 11. All content has been derived from references listed.00.ineedce. Verification forms will be mailed within two weeks after taking an examination. Was there any subject matter you found confusing? Please describe. or (216) 255-6619. 7) Make check payable to PennWell Corp. P. Date: _____________________ Charges on your statement will show up as PennWell Course Evaluation Please evaluate this course by responding to the following statements. Tulsa. Inc.com and click on the button “Take Tests Online. a division of PennWell AGD Code 074 ENDO0805DE 10 www. ext. go to www. Was the overall administration of the course effective? 5 5 5 5 5 5 4 4 4 4 4 4 Objective #3: Yes No Objective #4: Yes No 3 3 3 3 3 3 2 2 2 2 2 2 No No 1 1 1 1 1 1 8. Grading of this examination is done manually. 4. The California Provider number is 3274. How do you rate the author’s grasp of the topic? 6. Do you feel that the references were adequate? 9. Please e-mail all questions to: macheleg@pennwell. RECORD KEEPING PennWell maintains records of your successful completion of any exam.00 is enclosed. Please direct all questions pertaining to PennWell or the administration of this course to Machele Galloway. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Understand the types of instrumentation methods and their attributes for canal shaping and cleaning. INSTRUCTIONS All questions should have only one answer. What additional continuing dental education topics would you like to see? ___________________________________________________________________ ___________________________________________________________________ PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. SPONSOR/PROVIDER This course was made possible through an unrestricted educational grant from Sybron Endo. Please be sure to complete the survey included with the course. Participants are urged to contact their state dental boards for continuing education requirements.” Answer sheets can be faxed with credit card payment to (440) 845-3447. The cost for courses ranges from $49. Please contact PennWell for current term of acceptance. PennWell is a California Provider. No manufacturer or third party has had any input into the development of course content. Number: _______________________________ 0 0 0 0 0 0 Exp.com . CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. This report.ANSWER SHEET A Clinically Relevant Review of Nickel Titanium Canal Enlargement Name: Address: City: Telephone: Home ( ) Title: E-mail: State: Office ( ) ZIP: Specialty: Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course.  ayment of $59.00 to $110. 4) Mark only one answer for each question. Participants will receive confirmation of passing by receipt of a verification form. (216) 398-7922. and or the opinions of clinicians. 2. Please rate the instructor’s effectiveness. OK 74112 or macheleg@ pennwell.. ___________________________________________________________________ ___________________________________________________________________ 12. 3. Would you participate in a similar program on a different topic? Yes Yes 10. Educational Objectives 1. To find out if this course or any other PennWell course has been approved by DANB. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. 1. COURSE CREDITS/COST All participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive a verification form verifying 4 CE credits. EDUCATIONAL DISCLAIMER The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of PennWell. P (Checks and credit cards are accepted. If any of the continuing education questions were unclear or ambiguous. 5) A score of 70% on this test will earn you 4 CE credits.ineedce. (DANB) and can be used by dental assistants who are DANB Certified to meet DANB’s annual continuing education requirements. OH 44026 or fax to: (440) 845-3447 For immediate results. Mail completed answer sheet to Academy of Dental Therapeutics and Stomatology. 445. To what extent were the course objectives accomplished overall? 3. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please contact our offices for a copy of your continuing education credits report. Know the factors involved in safely performing endodontic therapy and how to minimize file fracture occurrence. Many PennWell self-study courses have been approved by the Dental Assisting National Board. using a scale of Excellent = 5 to Poor = 0.) If paying by credit card. please list them. 1421 S. Were the individual course objectives met? Objective #1: Yes No Objective #2: Yes No 2. 4.com.O. please contact DANB’s Recertification Department at 1-800-FOR-DANB. Sheridan Rd.com. A Division of PennWell Corp. AUTHOR DISCLAIMER The author has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. © 2008 by the Academy of Dental Therapeutics and Stomatology. Be knowledgeable about the factors involved in successful endodontic therapy. 7. Chesterland. 6) Complete the Course Evaluation below.

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