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MODERN ENDODONTIC PRACTICE

CONTENTS

Preface
Syngcuk Kim
Modern Endodontic Practice: Instruments and Techniques
Syngcuk Kim

xi

1

Like many other dental and medical specialties, endodontics has
evolved and changed over the years. The changes that have occurred in the last 10 years, however, have been of great magnitude
and profundity. The microscope, ultrasonic units with specially
configured tips, superbly accurate microchip computerized apex
locators, flexible nickel-titanium files in rotary engines, and greater
emphasis on microscopic endodontic surgery have totally changed
the way endodontics and endodontic surgery are practiced. Comparing these changes with formocreosol medication, K-file and
radiographic determination of working length are truly dramatic.
These changes are bringing the specialty of endodontic practice
into the twenty-first century with greater precision, fewer procedural errors, less discomfort to the patient, and faster case completions. Seven key advancements in endodontics were made in the
last decade. This article discusses these advancements and their
applicability to everyday practice.

The Microscope and Endodontics
Syngcuk Kim

11

The incorporation of the microscope in clinical endodontics has
had profound effects on the way endodontics is done and has changed the field fundamentally. This article outlines the key prerequisites for the use of the microscope in nonsurgical endodontic
procedures, discusses which procedures benefit from using the
microscope, and addresses the issue of cost versus patient benefit.

Nonsurgical Ultrasonic Endodontic Instruments
Mian K. Iqbal

19

The advent of nonsurgical ultrasonic tips has opened up a new horizon in endodontic treatment. There are a number of nonsurgical
VOLUME 48

Æ NUMBER 1 Æ JANUARY 2004

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endodontic ultrasonic systems currently available in the market
and it is difficult to review all of them. Based on similarities among
different instrument systems, an attempt has been made to classify
instruments into broad categories. This article describes the utility
of each type of ultrasonic tip and the principles behind its usage.
These instruments may be area specific or use specific, but can
be used in an area other than the one for which they are specifically
designed if the general principles regarding ultrasonic tips are
understood and applied.

Electronic Apex Locator
Euiseong Kim and Seung-Jong Lee

35

Locating the appropriate apical position always has been a challenge
in clinical endodontics. The electronic apex locator (EAL) is used for
working length determination as an important adjunct to radiography. The EAL helps to reduce the treatment time and the radiation
dose, which may be higher with conventional radiographic
measurements. According to recent publications, the accuracy of
frequency-dependent EALs appears to be much higher compared
with traditional-type EALs (simple resistance type or impedance
type). This article reviews the history and the working mechanism
of the currently available EALs, and suggests the correct usage of
the apex locator for a better canal length measurement.

Nickel–titanium: Options and Challenges
Michael A. Baumann

55

The introduction of nickel–titanium (NiTi) as material for endodontic instruments about 15 years ago opened many new perspectives.
Many dentists and scientists see a benefit in using NiTi files. Initial
problems such as frequent fractures and the uncertainty of the best
way to use them have been solved. Other challenges such as enhancing the cutting ability or optimizing the speed, torque, and fatigue are currently being addressed. Some clinicians are skeptical
because they see this approach as too mechanical. Nevertheless,
the combination of anatomic, biologic, and pathophysiologic
knowledge with the use of NiTi instruments is a large step forward
in optimizing the quality of root canal treatment worldwide.

The ProFile System
Yeung-Yi Hsu and Syngcuk Kim

69

The ProFile instruments were among the first nickel–titanium
(NiTi) instruments to be marketed. This article describes the
unique file design, clinical performance, safety concerns, and clinical applications of this system. Guidelines for NiTi rotary instrument usage need to be followed to minimize complications and
maximize benefits.
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CONTENTS

ProTaper NT System
Thomas Clauder and Michael A. Baumann

87

This article reviews the design and clinical use of the ProTaper NT
file system.

The LightSpeed System
Fred Barbakow

113

This article describes the use of an innovative, engine-driven, rotary, root canal preparation instrument. The geometric design of
this nickel-titanium instrument is totally different from currently
marketed manual or engine-driven stainless steel or nickeltitanium instruments. The thin, taperless, noncutting shafts of
LightSpeed instruments maximize the flexibility of the nickeltitanium alloy, particularly in the larger sizes. The three basic designs of the LightSpeed cutting heads and three different methods
for using the LightSpeed system are described. LightSpeed instruments enable larger apical preparations in curved canals with less
coronal flaring than is possible with most other techniques.

The K3 Rotary Nickel–titanium File System
Richard E. Mounce

137

The K3 rotary nickel-titanium file system by SybronEndo is a stateof-the-art rotary nickel–titanium endodontic instrumentation
method that combines excellent cutting characteristics with a robust sense of tactile control and excellent fracture resistance. The
K3 has universal applicability across a wide range of clinical indications. Although it is a complete instrumentation system, future
possibilities for hybrid instrumentation techniques that combine
the best features of K3 with other rotary systems hold promise.

Real World Endo Sequence File
Kenneth A. Koch and Dennis G. Brave

159

As a result of the quest for a better, simpler technique, Real World
Endo in partnership with Brasseler USA has developed a new endodontic file and sequence. It is hoped that this file and sequence
will satisfy many of the current demands of modern root canal
therapy and be user friendly. This article discusses the benefits of
a fully tapered preparation, the general design of rotary files, and
the specific design and use of Real World Endo Sequence File.

The Hybrid Concept of Nickel–titanium Rotary
Instrumentation
Helmut Walsch

183

The idea of the hybrid concept is to combine instruments of different file systems and use different instrumentation techniques to
CONTENTS

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manage individual clinical situations to achieve the best biomechanical cleaning and shaping results and the least procedural errors.
The hybrid concept combines the best features of different systems
for safe, quick, and predictable results. Several hybrid instrumentation sequences are presented and their limitations are discussed.

Obturation of the Root Canal System
Samuel I. Kratchman

203

With all the new technology that has been introduced in endodontics, there are now several ways to instrument and obturate root
canals. Practitioners often develop their own ‘‘hybrid’’ technique
after sharing ideas with several colleagues. The purpose of this
article is to describe a technique of obturation, hoping that others
may incorporate some aspects into their own ‘‘hybrid’’ style.

MicroSeal Systems and Modified Technique
Francesco Maggiore

217

The MicroSeal technique was introduced in 1996 and consists of a
nickel–titanium (NiTi) spreader, a NiTi condenser, a gutta percha
heater, a gutta percha syringe, and a special formulation of gutta
percha available in cones or in cartridges. It is considered a thermomechanical compaction technique that uses a rotary instrument to
plasticize the gutta percha and move it within the root canal apically and laterally. The MicroSeal technique together with the
author’s modifications may be a very important tool in the hands
of the endodontist. The MicroSeal system is able to preserve a conservative preparation and provide an adequate penetration by the
obturation instruments in the apical third. Knowledge of the technique’s indications and limitations represents an important step in the
learning curve for those practitioners who are willing to incorporate
a new obturation method into their clinical techniques.

Conventional Endodontic Failure and Retreatment
Ralan Wong

265

Technologic advancements in dentistry and specifically endodontics have vastly improved the quality of care rendered to patients.
These advancements allow clinicians to gain insight into the retreatment of failing root canals. Due to training, practice, and patience, clinicians can expand their capabilities alongside of these
technologic advancements to perform endodontic retreatments
with increased success.

Perforation Repair and One-step Apexification Procedures
Samuel I. Kratchman

291

As with any dental treatment, procedural mishaps can occur during
root canal therapy. One such occurrence is the perforation of a root

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CONTENTS

or pulpal floor. After a perforation occurs, the goals are to ‘‘sterilize’’
(decontaminate) the site and then seal the perforation. The material
most widely used in endodontics to seal perforations is mineral
trioxide aggregate (MTA). MTA is extremely biocompatible, and
it has been shown histologically that osteoidlike material grows
right into MTA. The technique of one-step apexification offers an alternative to drawn-out cases with several medicament-changing
appointments that often result in a failed attempt at root-end closure. With the favorable histologic response of MTA, this material
is the best current choice for this procedure. Completion of these
cases in an effective and efficient way allows for permanent restorations to be done in a more timely manner, prolonging the longevity
of these teeth.

Modern Office Design in the ‘‘Information Age’’
Garrett Guess

309

This article reviews the process of reaching the goal of modernizing
a new or existing endodontic office. Incorporating computer-based
technologies in the office requires significant planning, best achieved by forming a technology goal that addresses budget, knowledge base, and infrastructure issues. Making the transition to the
modern dental practice is expensive and time-consuming but also
profitable and exciting. Soon, all dental offices will be using digital
radiographic systems, video systems, and patient charting programs that use no paper documentation. As the computer familiarity and staff knowledge base increases with the growing use of
computers in society overall, finding the office personnel able to
harness the efficiency and power of the technology in the dental office will be easier. Through careful planning and formation of a reasonable technology goal, updating an old office or creating a new
modern endodontic practice with the technologies of today can
be an enjoyable reality from which clinicians and their patients
can benefit.

Endodontic Working Width: Current Concepts and
Techniques
Yi-Tai Jou, Bekir Karabucak, Jeffrey Levin, and Donald Liu

323

Root canal morphology is a critically important part of conventional and surgical endodontics (root canal therapy). Many in vitro
studies have recorded the scales and average sizes of root canals,
but there have been few clinical attempts to determine the working
width. In the absence of a study that defines what the original
width and optimally prepared horizontal dimensions of canals
are, clinicians are making treatment decisions without any support
of scientific evidence. This article provides definitions and perspectives on the current concepts and techniques to handle working
width—the horizontal dimension of the root canal system—and
its clinical implications.

Index
CONTENTS

337
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Dent Clin N Am 48 (2004) xi–xii

Preface

Modern endodontic practice

Syngcuk Kim, DDS, MPhil,
PhD, MD (hon)
Guest Editor

The purpose of this issue of the Dental Clinics of North America is to
inform our dental colleagues about the advancements of the theories and
techniques of modern nonsurgical endodontics. The microscope, nickel–
titanium rotary file systems, and the electronic apex locator have profoundly
changed endodontic techniques. As a result, the modern endodontic specialty practice has little resemblance to the traditional endodontic practice.
We, at the University of Pennsylvania (Penn), have been very fortunate to
assemble a group of young, forward-looking clinicians and academicians
from around the world to establish truly modern endodontic treatment concepts and modalities. It has been a global effort. Many of these Penn Endo
graduates, who contributed significantly to the advancements while at Penn,
are now teaching and practicing in different parts of the world and have
shared their ideas, experiences, and philosophies generously for this issue.
They are not only experts in their field in their countries but many are also
pioneers in this changing field. For that, this editor is extremely grateful.
The first article describes the way modern endodontics is practiced in an
endodontic specialty practice, briefly touching on the subject matter of each
article. In subsequent articles, the authors discuss the new generation of
instruments and new techniques in significant detail so that the readers can
develop a working understanding of the techniques. The clinical benefits of
the new treatment modalities far exceed our expectations. Cases are completed with greater precision, in less time, and with far fewer flare-ups
between visits. It is the rare patient who experiences discomfort or clinical
0011-8532/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.005

DDS.xii S. efficient procedure with a predictably successful outcome. MPhil. USA E-mail address: syngcuk@pobox. Kim / Dent Clin N Am 48 (2004) xi–xii complications. I would like to thank Mrs. but mostly a pain-free. PhD. I hope that readers share our excitement about the truly ‘‘new and improved’’ endodontics and our commitment to its practice. Twenty-first century endodontics is no longer the most dreaded experience anyone can imagine.B.upenn. John Vassallo of W. Jutta Do¨rscher-Kim at the University of Pennsylvania for her invaluable assistance in editing and Mr. Saunders Company for initiating this project and for his patience and support.edu . MD (hon) Department of Endodontics School of Dental Medicine University of Pennsylvania 240 South 40th Street Philadelphia PA 19104-6030. Syngcuk Kim.

and faster case completions. 1). School of Dental Medicine. In this article. this magnification has such an impact that E-mail address: syngcuk@pobox. PA 19104-6030. the advancements and their applicability to everyday practice are discussed (Fig. University of Pennsylvania. flexible nickel-titanium files in rotary engines.cden. The microscope The previous issue of the Dental Clinics of North America was devoted to the use and advantages of the microscope. DDS. MD(hon) Department of Endodontics. Briefly. ultrasonic units with specially configured tips. USA The specialty of endodontics has evolved and changed over the years like many other dental and medical specialties. Indepth discussion of each of these advancements is found in articles elsewhere in this issue. The question of why we need loupes or microscopes can be answered quite simply: loupes provide 2 to 4 magnification. have been of great magnitude and profundity. The proper use of the microscope in endodontic therapy provides an advantage over any other tools. and greater emphasis on microscopic endodontic surgery have totally changed the way endodontics and endodontic surgery are practiced.12. PhD.edu 0011-8532/04/$ . These changes are bringing the specialty of endodontic practice into the twentyfirst century with greater precision. 240 South 40th Street. The microscope. however. the microscope provides great magnification and illumination and functions as an extension of loupes (Fig. K-file and radiographic determination of working length are truly dramatic.2003. less discomfort to the patient. 2).upenn.1016/j. Philadelphia. Comparing these changes with formocreosol medication. fewer procedural errors. doi:10. MPhil. The changes that have occurred in the last 10 years. Seven key advancements in endodontics were made in the last decade. superbly accurate microchip computerized apex locators. Although small.002 . All rights reserved.Dent Clin N Am 48 (2004) 1–9 Modern endodontic practice: instruments and techniques Syngcuk Kim.see front matter Ó 2004 Elsevier Inc.

Kim / Dent Clin N Am 48 (2004) 1–9 Fig. (E ) Obtura II. The bright focused light and high magnification provided by the microscope results in endodontics of the highest. 2. most accomplished level. 1. (C) System B. Fig. (D) Spartan Piezo ultrasonic instrument. (B) Nickeltitanium rotary ProFiles. Key instruments for the modern practice.2 S. (A) Electronic apex locator. .

Nonsurgical tips come in two categories.S. the optimum magnification for endodontic practice ranges from 8 to 24 magnification (Fig. Do we need magnification that great? and. First. 3.’’ The advent of the microscope in modern endodontic therapy facilitates a primarily visually guided. distinguish between the chamber floor and dentin. The questions here are. Misssouri). the microscope is most useful for locating canals after the access is made. another canal is located and instrumented (C). anyone who is used to loupes cannot practice without them. 4). 3). Surgical tips are for root canal retropreparation. In conventional endodontics. in extension. Ultrasonic instruments There are two types of ultrasonic tips on the market: surgical and nonsurgical. and identify isthmuses and other small anatomic entities. Fenton. After removal of the dentin. The same tooth at 24 magnification (B) that shows dentin covering the pulpal floor. A completely instrumented madibular first molar at 4 magnification (A). detect microfractures. of which recognition and treatment are so important for endodontic therapy success. secondarily sensory-aided endodontic procedure (Fig. the Buc tip is used for conventional cases such as cleaning the chamber so that endodontists can visualize the chamber without dentin debris (see the article by Kim elsewhere . What is the optimum magnification for endodontic procedures? In the author’s opinion. and there are many types available (see the Obtura/Spartan Company Web site. These are procedures that previously were done largely by ‘‘feel. It is extremely useful for post removal using ultrasonic instruments and for perforation repair. The high magnification is needed to locate hidden canals. Kim / Dent Clin N Am 48 (2004) 1–9 3 Fig. The microscope provides 4 to 25 magnification.

1A). Over 90% of the post can be removed by CPR tips driven by a Piezo ultrasonic instrument. Advancements in microchip technology led to the design of a better apex locator. making the radiographic determination of root canal length nearly obsolete. A second type of nonsurgical ultrasonic tip is the CPR tip. with much less gouging or damaging the dentin structure around the post than with burs. This ultrasonic instrument is a lifesaver when calcified canals are encountered. The correct use of the locator always identifies the root end . even the smallest burs unnecessarily remove large amounts of dentin compared with CPR tips. openings to calcified canals. Buc tip size 2). and removal of posts and/or separated files (C). High. The microscope is best used for repair of perforation (A). 4. sometimes microscopic. in this issue. the author’s unequivocal answer would be the electronic apex locator (see Fig. the electronic apex locator has become the most important and essential instrument in endodontic practice. identification or detection of microfractures (B). After the microscope.4 S. Cleaning the pulp chamber is also an important prerequisite for inspection of the chamber for anatomic details. 8]). These tips are used mainly for post removal. Electronic apex locator If asked what the most important advancement in endodontics in the recent decade is. This cleaning can be done best with a diamond-coated small microburner tip (eg. Microscopic observation is not effective when the chamber floor is full of dentin debris that is created by burs. [Fig.or low-speed burs are much too large to ‘‘catch’’ the minute. Although posts can be removed with burs. The sharp-ended tips allow clinicians to pick and explore the chamber floor to identify canals. Kim / Dent Clin N Am 48 (2004) 1–9 Fig.

Varying tip sizes determine the depth of penetration (ie. One salient . This technique is now called ‘‘Flintstone-age endodontics. This precision is needed to minimize intervisit flare-ups. now there are so many. At the time of this writing. This practice has contributed greatly to pain-free treatments without flare-ups and with longterm healing success—almost impossible 10 years ago. with new ones being introduced every year. System B or ‘‘Touch’n Heat’’ In the ‘‘old’’ days—only 10 years ago—a torch or open flame was used to sear or melt the gutta percha. In the author’s department.’’ Thermoplastesized gutta percha was used in endodontics before the invention of this compactor. 1E). postgraduate students rely more on their apex locators than on radiographs.S. Obtura compactor The Obtura compactor is another innovation in modern endodontic practice that has become a ‘‘must have. Now there are numerous NiTi rotary file systems available (see Fig. the procedure was done in the canal using hot instruments. In this manner. the canal is more homogeneously and densely filled. The use of the compactor is especially useful when dealing with internally resorbed canals that cannot properly be filled. overfillings. the thinner the tip. and underfillings. Kim / Dent Clin N Am 48 (2004) 1–9 5 correctly.’’ The System B and ‘‘Touch’n Heat’’ (SybronEndo. there was only one system. California) allow a safer means to heat the gutta percha (see Fig. 1B). with S-Kondensers) to obturate the canal. Nickel–titanium files The nickel–titanium (NiTi) revolution took place in the mid-1990s. It has been shown that the resulting temperature elevations within the canal do not damage the periodontal ligament. even with the lateral condensation technique. With the advent of this instrument. This thermoplastesized gutta percha is then condensed (eg. In 1980. and the gutta percha is thermoplastesized. The obturation technique using System B is gaining popularity among endodontists and is gradually replacing the old technique. Specially designed tips of varying sizes are connected to the System B and are heated instantly to the desired temperature by touching a sensor on the handle. This development is similar to the titanium implant development some years ago. there are over 20 different types of NiTi rotary file systems available. the deeper the penetration). however. A tip is inserted into the obturated canal. gutta percha is thermoplastesized in a specially designed gun that is connected to an electronically controlled unit (see Fig. 1C). Orange. the sensor to heat the tip is activated.

endodontists will be able to improve the quality and esthetics of their endodontic obturations quickly. however. and others that are passive with a negative rake angle that mill the dentin. it has proved to be the best material for most types of perforation. In a moist environment. Oklahoma) with a negative rake angle. The NiTi file systems are very convenient for ‘‘milling’’ the canal but not for cutting the canal dentin. The author considers the NiTi file system not a must-have instrument.02 to 0. In conventional endodontics. Although there are many pitfalls on the road to consistent results. Anatomy of modern endodontic practice Excellent and consistent endodontic outcomes are still very difficult to obtain.02-type handle with varying file tip diameters.6 S. with proper use of the NiTi systems. This breakage can be minimized greatly by light-handed and careful use. There are basically two types of NiTi systems: the LightSpeed (LightSpeed. and even as an endodontic filling material for apexification. Cutting the dentin is usually done with Gates–Glidden burs or K files in combination with NiTi rotary files. The non-LightSpeed types include active systems with a positive rake angle that cut the dentin. Texas) and the non-LightSpeed types. thereby creating a perfect seal and an ideal barrier. the canals can be prepared more easily and uniformly. Tulsa. but rather a convenient instrument. Kim / Dent Clin N Am 48 (2004) 1–9 question is. The LightSpeed type is a miniaturization of the Gates–Glidden bur. it handles like sand and some clinicians have compared it to Portland Cement. the most popular type is the ProFile (Dentsply. along with a thorough knowledge of the root canal anatomy and endodontic practice. it also has been advocated for pulp capping. MTA is a mixture of many oxides and looks like grayish-brown sand. More recently. Each of these systems offers files ranging from 0. It has been shown in numerous studies and in clinical practice that it is the only material into which bone and cementum cells actually grow. Mineral trioxide aggregate Mineral trioxide aggregate (MTA) is a reliable new endodontic material initially designed as a retrofilling material. This is a material that has long been on the endodontic wish list because perforations during endodontic procedures or during post preparation are not that uncommon. By using these instruments. far better and more consistent results can be obtained . In fact. Will NiTi file systems replace the stainless steel K-file system? The answer is definitely not. Some clinicians avoid the NiTi rotary systems due to breakage of the file tip inside of the canal. For instance. San Antonio.12 taper with smaller tip diameters. with a 0. perforation repair. it sets in about 7 hours. With the incorporation of the new generation instruments. Its unique physical property is its compatibility with bone.

access is made. a more accurate canal length measurement is possible because coronal interference has been eliminated. an itemized sequence follows: 1. Rome. 8. At high magnification. (Courtesy of F. To illustrate the modern endodontic procedural sequence of a normal case of a maxillary first molar. 6). 10. Following placement of the rubber dam. 9. The microscope is not needed for this step. 4. An apex locator is used to determine the canal length at this stage. a fourth canal (MB2) of a maxillary first molar can easily be detected (A) and is shown with a size 10 file in the canal entrance (B). Using the microscope at low to mid magnification. . although some clinicians may prefer to use it. Italy. During this enlargement. the microscope is not needed until a later stage. DDS. 5). Maggiore. The apex is negotiated with a size 10 K file and is then enlarged with size 15 or 20 files.S. 3. 6. In this manner.) than in the past. Kim / Dent Clin N Am 48 (2004) 1–9 7 Fig. NiTi rotary instruments are now employed to prepare the remaining one half or one third of the apical canal in the crown down manner. A master gutta percha cone is selected. 5. the floor of the chamber is examined for additional canals because more than 50% of molar teeth have a fourth canal (Fig. it is important to use irrigants (2. The final apical preparation or determination of the master apical file is done by hand instruments or LightSpeed. Gates–Glidden burs are used in reverse order to enlarge the coronal one half or two thirds using the crown down technique. Under high magnification (16–24). 7. 5. The diagnosis indicates that endodontic treatment is needed and the tooth is anesthetized. 2. depending on the original canal width or estimate of working width. the pulp chamber is thoroughly prepared using a Buc tip size 2 for inspection. After the canal entrance is identified. The microscope is used to check the preparation and to check again for an additional canal or canals (the author has found up to six canals in molars)(Fig.5%–5% sodium hypochlorite and 17% EDTA solution) to penetrate deep into the canals. the canal length and solid ‘‘tug back’’ is assured.

8 S. fewer procedural errors. Finally. Radiograph of the maxillary first molar prior to endodontic therapy (A) and microscopic examination of the prepared four canals at 24 magnification of the same tooth (B). The Obtura gutta percha compactor with an appropriate tip is inserted into the canal up to where the master gutta percha was seared off. 7. is inserted into the canal. 12. 13. The purpose of incorporating these advanced instruments is to perform endodontic procedures more accurately. 6. Multicanal cases done by endodontic graduate students at the University of Pennsylvania using the modern instruments and techniques described in this article. thus experiencing less postoperative discomfort. the canal is sealed with temporary cement. Kim / Dent Clin N Am 48 (2004) 1–9 Fig. and a more efficient procedure. The thermoplastesized gutta percha fills the canal as the tip is slowly withdrawn. 11. This brief sequence shows the use of modern endodontic instruments. This master cone. Although the ultimate criteria (ie. whether the incorporation of these Fig. The microsocpe is used again for a final check. . coated with root canal cement. The gutta percha in the apical 3 to 4 mm is packed with S-Kondensers. and the coronal part of the point is seared off using System B.

7).S. These improvements are truly significant. the author’s clinical experience of the last 10 years has shown that the procedures are more predictable. and result in fewer flare-ups and less discomfort for patients. with a significant increase of over 40% in locating fourth canals in molars (Fig. . Kim / Dent Clin N Am 48 (2004) 1–9 9 instruments provides greater treatment results and success) has still not been established in a formal study. and reliable. In addition. the radiographic results are far better. efficient.

Prerequisites for the use of the microscope in nonsurgical endodontics Rubber dam placement The placement of a rubber dam prior to any endodontic procedure is an absolute requirement for sterility purposes. There are many microscopes on the market. the incorporation of the microscope in clinical endodontics has had profound effects on the way endodontics is done and has changed the field fundamentally. If the mirror were used for this purpose without a rubber * Corresponding author. This article outlines the key prerequisites for the use of the microscope in nonsurgical endodontic procedures. Seungho Baek. This was a giant step forward in the advancement of endodontics. the microscope was first introduced to otolaryngology around 1950. Dentistry.upenn. USA b Department of Conservative Dentistry. DDS. therefore. is about 40 years behind medicine in this respect. According to the Zeiss Company. 1. All rights reserved.001 . the three most popular ones are presented in Fig. PhD.2003. PA 19104-6030. Seoul National University. For this reason. Philadelphia.Dent Clin N Am 48 (2004) 11–18 The microscope and endodontics Syngcuk Kim. 240 South 40th Street. This technique is taught at all dental schools. the rubber dam placement is necessary because direct viewing through the canal with the microscope is difficult. As in medicine. the 1998 American Dental Association accreditation requirement change states that all accredited United States postgraduate programs must teach the use of the microscope in nonsurgical and surgical endodontics. then to neurosurgery in the 1960s. and to endodontics in the early 1990s. PhDb a Department of Endodontics.1016/j. if not impossible.cden.*. E-mail address: syngcuk@pobox.edu 0011-8532/04/$ . doi:10. Here. the purpose is greater. In endodontics. MPhil. Korea It may seem surprising that the microscope is not a high-tech instrument. A mirror is needed to reflect the canal view that is illuminated by the focused light and magnified by the lens of the microscope. Seoul.see front matter Ó 2004 Elsevier Inc. School of Dental Medicine. DDS. University of Pennsylvania. MD(hon)a. however.12. It has been used in the medical field for over 50 years.

S. The three most popular microscopes in endodontics. Baek / Dent Clin N Am 48 (2004) 11–18 Fig. it is recommended to use blue or green rubber dams (Fig. .12 S. 1. 2). Kim. then the mirror would fog immediately from the exhalation of the patient. the powerful microscope magnification and illumination would be rendered totally useless for the necessary visualization of the chamber floor and the canal anatomy. To absorb reflected bright light and to accentuate the tooth structure. Thus. Fig. dam. 2. The use of a rubber dam is essential for effective microscope use.

but negotiating the canal with Fig. however. If the mirror is placed close to the tooth. If a rubber dam has been placed. it is nearly impossible to view the pulp chamber directly under the microscope. Baek / Dent Clin N Am 48 (2004) 11–18 13 Indirect view and patient head position As mentioned previously. at times. then it will be difficult to use other endodontic instruments. the patient’s head is adjusted to create a 90 angle between the maxillary arch and the binocular (Fig. making the entire operation time-consuming and. Kim. the mirror placement will be close to 45 for best viewing. With practice. In this position. .S. clinicians must use specially designed microinstruments. and the clinician should be able to obtain this angle without requiring the patient to assume an uncomfortable position. Instead. the ‘‘correct’’ placement of the mirror will become automatic. Some key instruments The ability to locate hidden canals is the most important and significant benefit gained from using the microscope. The optimum angle between the microscope and the mirror is 45 . To do this effectively and efficiently. the view seen through the microscope lens is a view reflected by way of a mirror. the position of the patient (especially the head position) is important (Fig. This is especially true during a lengthy perforation repair. 4). such as a moldable pillow. then the mirror must be placed away from the tooth within the confines of the rubber dam. The maxillary arch is rather easy for indirect viewing. Patients should wear protective dark glasses and have support for the neck. 3). Mouth mirror placement It is always a good idea to use the best mirror for this purpose. An explorer can pick the entrance of a canal under the microscope. 3. S. To maximize the access and quality of the view by this indirect means. Basically. Readjusting the mirror will necessitate refocusing of the microscope. frustrating.

5). S. can be easily achieved under the microscope. 5. After the canal is located in this manner. have with different sized tips and can be extremely useful (Fig.14 S. clinicians can instrument the canal normally without the microscope. verifying that the ‘‘catch’’ is truly a canal. facilitating the subsequent steps of canal instrumentation. a file can be challenging because there is only a tiny space between the mirror and the tooth for a finger with a file to move around. Fig. Files specially designed by Maileffer. Positioning the microscope. Notice the ergonomics of the clinician and comfortable patient position. 4. . however. Micro-openers by Maillefer are ideal instruments for exploration of hidden canals at high magnification. Baek / Dent Clin N Am 48 (2004) 11–18 Fig. These hand-held files allow the clinician to initially negotiate the canal. The use of Gates–Glidden burs to enlarge the canal entrance prior to full instrumentation. called microopeners. Kim.

Locating hidden canals As discussed in many sections in this issue. A persistently painful tooth after endodontic therapy may be due to an untreated missing canal (eg. Following the introduction of the microscope to the Graduate Endodontic Program at the University of Pennsylvania in 1992. Methylene blue staining of the microfracture area assists this effort greatly. Diagnosis The microscope is an excellent instrument to detect microfractures that cannot be seen by the naked eye or by loupes. Re-examination of the chamber at high magnification under the microscope may locate the missing canal (see the article by Kim elsewhere in this issue [Fig. any microfracture can be easily detected (Fig. All endodontic textbooks have information on molar teeth with three canals. and anterior teeth with one canal.S. This may a noble idea. The canal anatomy is extremely complex. . it has been Fig. It has been the author’s experience at the University of Pennsylvania Graduate Endodontic Clinic that the main cause of a symptomatic tooth following radiographically satisfactory endodontic therapy is an untreated canal. dental anatomy is not that predictable. Kim. S. Under 16 to 24 magnification and focused light. Baek / Dent Clin N Am 48 (2004) 11–18 15 For what procedures is the microscope really essential? Some enthusiasts claim that the microscope must be used for all steps of nonsurgical endodontic procedures. Arrows identify the fracture line. MB2 in a maxillary molar). 5]). Microfracture detected under the microscope (A) and the same tooth after extraction (B). it is not needed or desired. A clinician must consider the benefit/risk ratio when using the microscope. The following procedures are those that benefit from the use of the microscope. premolars with two canals. the most important utility of the microscope in nonsurgical endodontics is locating hidden canals. Often. 6). but in reality. 6.

Fenton. the microscope is an invaluable tool in clearly detecting the bifurcation and the two separate canals. and close to 25% of all anterior teeth have two canals. the microscope allows the clinician to detect and prepare conservatively. 7.16 S. calcified canal in the pulp chamber is not detectable. Buc tips (Obtura/Spartan) are ideal ultrasonic instruments for cleaning the pulp chamber and floor for clear viewing of the canals. Baek / Dent Clin N Am 48 (2004) 11–18 found that nearly an astounding 50% of all molars (maxillary and mandibular) have a fourth canal. Management of calcified canals With normal vision or low-power loupes. 7). When a perforation occurs. There are teeth where the canal bifurcates at 3 to 5 mm into the canal and in the maxillary second molar. the microscope is the key instrument to identify and evaluate the damaged site. Considering this as the benefit of using the microscope for endodontic procedures is obvious. S. Missouri) will allow clinicians to detect and negotiate the calcified canal easily (Fig. The results of a careful inspection will be the basis for which the preparation of the Fig. Kim. Sometimes in these cases. . When the calcified canal is looked at through the microscope at high magnification. the ultrasonic preparation of the canal or canals has to go as far as a couple of millimeters short of the apex. the difference in the color and texture between the calcified canal and the remaining dentin can be easily seen. 8). Perforation repair Perforation does occasionally occur no matter how carefully the tooth is accessed for endodontic therapy. Again. Careful probing and ultrasonication using CPR or Buc tips (Obtura/Spartan. and not to gouge the healthy dentin structures (Fig. What was considered a rare exception in the past has become a routine finding when using the microscope. where the MB and DB are in very close proximity of each other. more than 30% of all premolars have a third canal. however.

the microscopic procedure is to place a matrix precisely. If the file breaks within the coronal half of the canal. S. then the microscope is essential to guide the clinician to retrieve the broken files. Access preparation and management of calcified canals at a high magnification under the microscope (A–F ). mineral trioxide aggregate is packed against the matrix. . Rome. Briefly. then there is still remnant pulp tissue in the canal. Final examination of the canal preparation It takes a simple step to see whether a canal is completely cleaned. In this manner. Retrieval of broken files With the more frequent use of nickel-titanium rotary files in general dentistry. (Courtesy of F.S. Kim. the microscope cannot be of help. If there are bubbles coming from the prepared canal. the canal needs more cleaning. a small amount of sodium hypochlorite. the broken file can be removed while minimizing the damage to the surrounding dentin. Maggiore. overfill. 8. however. or underfill. Baek / Dent Clin N Am 48 (2004) 11–18 17 Fig. just exterior of the root substance). This procedure requires delicate and careful handling of the materials so as not to extrude. When the file is broken at the apex. a popular irrigation solution. the incidence of file separation within the canals has increased. DDS. In short. just outside of the perforation site (ie. The microscope is essential for this procedure. is deposited into the canal and observed carefully at high magnification. After the matrix is placed. Italy) perforation repair will be made (see the article by Kratchman elsewhere in this issue). The matrix can be calcium sulfate or resorbable collagen. Under the microscope.

endodontic procedures can be done in less time because of the greater visibility of the root canal anatomy. after the initial learning curve. Another benefit of the microscope is the flexibility with documentation. Procedural errors can be greatly reduced. not just selected ones. and complicated cases become less so under the microscope. The information can then be shared with referring dentists or patients and the images are. In addition to clinical benefits associated with the use of the microscope in endodontics. Kim. Clinicians should also become totally committed to using the microscope in each of their treatment cases. . Compared with intraoral video cameras. if not eliminated. Baek / Dent Clin N Am 48 (2004) 11–18 Cost versus patient benefit Many of the practitioners who perform endodontic procedures and do not yet own a dental microscope are still evaluating the benefits of its use. This practice is the fastest route toward proficiency and the best way to maximize the return on investment. Practicality is the key concern. clinicians should take an intensive training course at the very beginning to make them comfortable with handling the microscope and with working underneath it. of course. microdental images can be captured on computer or digital camera. How does one recoup the cost of the capital expenditure and the cost and time associated with training? Are the clinical benefits worth the expenditure of time and money? To address the critical cost and efficiency issue.18 S. also required information for the patient record. S.

root canal obstructions are being removed in a more conservative manner that does not unnecessarily destroy the root structure.upenn. Iqbal. endodontic retreatment has become the procedure of choice. instead the clinician is now able to maintain visual contact with the operating field at all times during ultrasonic procedures. Teeth with root canal obstructions are no longer automatically treatment planned for surgical endodontics. DMD.1016/j. The combination of ultrasonic instruments with the E-mail address: miqbal@pobox. in addition to an unobtrusive view under the microscope. The identification of missed and hidden canals has become a predictable outcome rather than a serendipitous discovery. doi:10. Philadelphia. the only thing needed to make a modernday ultrasonic instrument was incorporation of a contra-angle bend and parallel working ends. All rights reserved.see front matter Ó 2004 Elsevier Inc. PA 19104-6030. Because the operating field is so restricted. BDS. MS Department of Endodontics. which in turn necessitated the evolution of a number of microendodontic instruments. Cutting dentine structure with ultrasonic tips is analogous to cutting dentine with the thinnest bur imaginable. In addition.001 . The contra-angle design allowed for dramatic improvement in procedural access for both anterior and posterior teeth. Ultrasonic technology has been available for a long time [1]. Ultrasonic instruments play an ever-increasing role in several aspects of endodontic treatment. opening up gateways to better endodontics.cden. Above all. 240 South 40th Street. Among these.Dent Clin N Am 48 (2004) 19–34 Nonsurgical ultrasonic endodontic instruments Mian K. The ultrasonic technique is essentially a nonrotary method of cutting dental hard tissue and restorative materials using piezo-electric oscillations. Access cavities are being cut and refined with greater precision. University of Pennsylvania. The Robert Schattner Center. the use of high magnification and proper illumination is essential during the use of these instruments.edu 0011-8532/04/$ . School of Dental Medicine.10. these procedures are no longer being performed blindly. USA One of the most important advancements in endodontics has been the use of the surgical operating microscope.2003. ultrasonic instruments have improved the most.

Missouri). Both the CPR and ProUltra systems also are accompanied by a set of slender and long tips made from titanium alloys (Fig. Japan) uses stainless steel tips that are effective and very economical (Fig. Oklahoma). except that they are diamond coated and have built-in water ports (Fig. Today. The advantages of a wet field include easier washing of the field and the cooling effect. These tips are designed to function dry. The Enac ultrasonic endodontic system (Osada Electric Co. Iqbal / Dent Clin N Am 48 (2004) 19–34 magnification and illumination provided by surgical operating microscope has been termed microultrasonics. varying in complexity from simple curves to multiangled bends. These instruments are designed primarily to function on Spartan Piezo-Electric units (Obtura/Spartan.K. However. Almost all of the currently available systems provide the option for using ultrasonic instruments in a wet or dry field.. California) is another popular system that is geared for troughing around posts and opening calcified canals (Fig. 2). The ‘‘4’’ series (Sybron Endo. This allows the clinician to maintain visual contact with the operating field at all times during the procedure. Stainless steel tips may be coated with zirconium nitride or diamond grit to increase efficiency and durability. . Orange. Titanium alloy provides flexibility and greater vibratory motion to the tips. Dentsply.20 M. 4) access refinement tips (Spartan instruments) have been introduced to the market. Tokyo. the area must be dried to provide the clinician with a clearer view of the operating field. ultrasonic tips are being made and coated with different materials. The BUC tips also are diamond coated and have built-in waters ports that constantly bath the activated tips. and made of different materials such as stainless steel or titanium alloys. Some tips are designed to function dry. ultrasonic instruments also have been manufactured with a coating of zirconium nitride (ProUltra ultrasonic instruments. Recently. The device attaches to a standard quick-change air–water syringe and can be used to blow air on the field to maintain visibility. CPR ultrasonic instruments (Spartan CPR instruments. Fenton. but also prevents the development of localized emphysema. To improve efficiency. West Collins Orange. 3). Missouri) are similar in design to the ProUltra instruments. The irrigator not only delivers a controlled stream of water and air to precisely irrigate and dry the operative field. Tulsa. These tips can be long and slender or short and sturdy. they also can be end cutting or side cutting. A Stropko surgical irrigator (EIE/Analytic Technology. Fenton. a set of BUC (Fig. Diamond-coated tips purportedly last longer and are associated with greater efficiency when compared to uncoated or zirconium nitride-coated tips. A variety of ultrasonic tip designs are available. whereas others come with water ports to increase the cooling and washing effect. 1). 5). A thorough understanding of these and other variables is critical for the proper selection and usage of ultrasonic tips. California) may be used to work continuously in a dry field. These tips are end cutting and are employed for cutting deep inside the root canals.

2. Iqbal / Dent Clin N Am 48 (2004) 19–34 21 Fig. Breakage of ultrasonic tips is a common phenomenon. is used for removing solids from root canals. Retreatment CPR tips 2D through 5D are diamond coated with built-in water ports that allow for wet or dry cutting.K. The ST21. However. The bottom picture shows the vibratory tip ST09. some of these tips are quite expensive and must be used properly to avoid unnecessary breakage.M. shown at the top. these tips usually jump out of the canal or can be retrieved easily. The most common reason that tips break is because Fig. Once broken. Two tips from the Osada Enac ultrasonic endodontic system. . 1.

4. they are not operated at their recommended frequencies. Therefore.K. it is important to follow the manufacturer’s recommendations with regard to the ultrasonic intensity at which a particular tip must be used. BUC access refinement tips 1 through 3. . The results of a recent study [2] revealed a significant increase in displacement amplitude Fig. Titanium CPR ultrasonic tips 6 through 8. Iqbal / Dent Clin N Am 48 (2004) 19–34 Fig. 3.22 M.

tips that are used for bulk removal of dentine or restorative materials (eg. however. The troughing tips (eg. CPR 6–8) will fracture easily when used at high intensity. Similarly. tips that are designed primarily for cutting dentine can break . the slender and longer tips with small cross-sectional diameters (ie. excessive angulations also make these tips more vulnerable to breakage [3]. short and sturdy tips used for vibrating posts out of root canals are operated at medium-high intensity. CPR 3D–5D. The ‘‘4’’ series is specially geared toward post removal. However. On the other hand.M.K. In addition. CPR 2) also need to be used at moderate to high intensities. thick and short tips are operated at higher intensities. whereas long and slender tips are operated at lower intensities. and depth of dentine cut with an increase in power setting. 5. Iqbal / Dent Clin N Am 48 (2004) 19–34 23 Fig. In general. Tips with bends increase access to different parts of the mouth. BUC 3. and CPR 6– 8) should be used at low intensity.

K. Although a number of other systems are available. however. it is possible to use an ultrasonic tip in an area other than the one for which it is specifically designed if the general principles regarding ultrasonic tips are understood and applied. A properly designed access cavity that provides direct line access to all the root canals is key to endodontic success. However. to experience the full range of power. A properly designed access cavity should allow for placement of endodontic instruments in the root canals in the same manner as flowers are placed in a vase. Recently. Iqbal / Dent Clin N Am 48 (2004) 19–34 easily if inadvertently brought into contact with metals. it becomes more beneficial to know the utility of each type of ultrasonic tip rather than the system as a whole. and (4) troughing tips. otherwise. However. which is capable of generating ultrasonic frequencies in the range 20 kHz to 30 kHz. a combination of access refinement ultrasonic tips and magnification has revolutionized the basic concept of access cavity preparation. At the present time. There are many advantages to using ultrasonic tips rather than burs to refine the access cavity to locate the underlying anatomy. The shanks of ultrasonic instruments come in different lengths ranging from 15 mm to 27 mm. Access refinement tips Access cavity preparation is the most important phase of endodontic therapy. contact with the cutting surface should be broken temporarily to allow the tip to regain its oscillations. the instrument may loosen during use. it is not possible to describe all of them in this article. Not doing so may cause breakage of the instruments. access cavities have been refined with burs that were designed primarily for operative preparations. The instruments are selected according to the depth at which they will be required to operate inside the root canal. the components of the different ultrasonic systems have been broadly classified as follows: (1) access refinement tips. With this in mind. Traditionally. For greater control. From a practical point of view.24 M. therefore. These frequencies generate comparable patterns of oscillation at the tip of the instruments. To be effective. There is no handpiece head to obscure vision and. the progressive cutting . (3) bulk removal tips. the use of these instruments in patients with cardiac pacemakers is not recommended. Also. the shortest tip possible to reach the desired depth should be used. these instruments must be kept moving at all times. Each instrument system usually comes with its own ultrasonic engine. These instruments can be separated into two categories—area specific or use specific—and come with established guidelines. a closer look at the different systems reveals a number of similarities. a wrench should be used to tighten the instruments in place. (2) vibratory tips. oscillation of the ultrasonic tip may be stalled if it is introduced into narrow canals or forcefully applied against dentine or restorative material. If the instrument begins to stall.

For pulp chambers that have receded with calcification. A number of tips are available to refine the access cavity. The remaining chamber contained remnants of sealer cement and necrotic tissue. The size of ultrasonic tips is smaller than the smallest burs. (B) Removal of gutta-percha filling and use of ultrasonic instruments exhibits debridement of the chamber and the presence of an untreated fourth distal canal. colored floor of the pulp chamber is not visible. the term ‘‘uncovering’’ the floor of the pulp chamber is more appropriate. 7). 6.M. Therefore. it is no wonder that access cavities prepared with ultrasonic instruments have a thoroughly washed out and clean appearance (see Fig. therefore. however. this term is valid only when dealing with young and large pulp chambers.K. it usually is obscured by pulp stones or tertiary dentine deposits (Fig. The process allows for exposure of any missed or hidden canals or recesses containing necrotic pulp tissue without gutting down the tooth structure (Fig. 7A). Cavitation may be described simply as bubble activity in a liquid. Fig. the dentine can be brushed off in smaller increments and with greater control. The process is similar to archeologists unearthing artifacts at excavation sites. which is capable of generating enough shock waves to cause disruption of remnants of necrotic pulp tissue and any calcific deposits. The unveiling of the dark-colored floor of the pulp chamber is of critical importance because it dictates and guides the extension of access cavity. The uncovering of the floor of the pulp chamber can be accomplished with the help of the CPR 2D or BUC 1 tips. (A) Mandibular molar requiring retreatment shows presence of gutta-percha in two mesial and one distal canal. The tip of this instrument is designed with a planed surface and it can grind the floor until the dark-colored dentine becomes visible. they can be planed with the help of a BUC 2 tip—a process similar to planing the root surface. at other times. 6). The pulp stones sometimes can be vibrated or teased out by the CPR 2D or BUC 1 tips (see Fig. Another advantage of ultrasonic instruments over burs is the production of cavitation within the cooling water that flows over the tip of the ultrasonic instrument [4]. 6B). The dentine must be brushed off in smaller increments until the road map on the floor of the pulp chamber is uncovered completely. . The usual term used for this procedure is ‘‘unroofing’’ the pulp chamber. If the dark. Iqbal / Dent Clin N Am 48 (2004) 19–34 25 action can be observed directly and continuously under the microscope.

this procedure must be accomplished by a number of radiographic checks and restricted to the coronal aspect of the . The groove should not be extended toward the palatal canal but rather in a direction slightly mesial to it. (D) Continued removal of calcification and refinement of access cavity with ultrasonic instruments exposes the floor of the pulp chamber and the presence of an additional distobuccal canal. The refining tips also are used for moving the mesial marginal ridges mesially to have a direct line access to the MB2 canal [7]. Iqbal / Dent Clin N Am 48 (2004) 19–34 Fig.K. Germany. (B) The use of ultrasonic energy led to shattering of pulp stone. 7. Helmut Walsch. (C) This picture reveals the presence of four root canal orifices.26 M. but the absence of any pulpal floor road map. the tips also can be used for delineating the outlines of the root canal orifices so that the overhanging dentine deposits are removed and the orifices are exposed. The refining tips can accomplish this task in a much-controlled manner by deepening the groove while at the same time restricting its mesiodistal dimension so as to not perforate the furcal or mesial aspect of the tooth. A protocol involving deepening of the bucco-lingual groove overlying the mesiobuccal root is essential for locating the MB2 [6].) The second mesiobuccal canal (MB2) is reported to occur in more than 90% of maxillary molars [5]. (A) An ultrasonic tip is being used to remove heavy calcific deposits on the floor of a maxillary molar pulp chamber. it is located 1. In addition. However. The ultrasonic tips can be used to dig and follow the sclerosed canals until patency is achieved. so as to follow the bucco-lingual orientation of the mesiobuccal root. On average. (Courtesy of Dr. Munich.8 mm away from the mesiobuccal canal in a palatomesial direction. This step sometimes can reveal the presence of two canals in a single orifice and helps to guide the instruments easily in and out of the canals.

The VT (Sybron Endo). such as root fracture or perforation. Osada Enac ST09. The test site is filled with thermoplastisized gutta-percha and an orientation radiograph is exposed (Fig. an ultrasonic tip is used to dig a test hole at the most probable site of the sclerosed canal. The ultrasonic tip was not aligned parallel to the long axis of the tooth and needed to be redirected to avoid root perforation. 8. and do not provide any information regarding the bucco-lingual depth of the tooth structure. To check progress. otherwise. the direction of the cutting is modified according to information gathered from the radiograph. A check radiograph of a calcified central incisor showing an ultrasonically prepared test site filled with radiopaque gutta-percha. Radiographs are two dimensional in nature. The tips of these instruments are spherical or flat and are placed against the post to transmit vibration. Iqbal / Dent Clin N Am 48 (2004) 19–34 27 root trunk only.K. This procedure also has been fraught with unwanted consequences.M. The implementation of ultrasonic energy has provided the clinician with an important adjunctive method for removal of posts. and CPR 1 are examples of such instrument tips. however. A number of studies [8–11] have shown conclusively that the use of ultrasonic vibration significantly reduces the amount of tensile force required to dislodge both the cast and prefabricated posts. If the test site is found centered in the root and pointing correctly. They Fig. 8). then cutting is continued to enter the canal. . Vibratory tips Removal of intraradicular posts has always been a challenge when performing endodontic retreatment.

troughing around root canal obstructions can be performed in a predictable and controlled manner. The controlled and incremental cutting with ultrasonic instruments under magnification provides a clear contrast between the core materials—for example. troughing around the root canal obstruction was performed with trephine drills. Bulk removal tips Bulk removal tips are extremely sharp and sturdy tips that are operated at moderate or maximum intensity of the ultrasonic unit. This process was extremely destructive and frequently led to the gutting down and perforation of root trunks. the troughing tip should be used around the post and then vibratory tips should be reapplied to obtain the maximum benefit. In retreating cast post and cores. This gives the clinician a purchase point to apply extraction devices when normal vibratory motions fail to dislodge the post completely. probably due to the lack of the microfracture propagation in these materials [12]. between composites and the underlying dentinal structure. Both of these tips are diamond coated and have an added advantage of a water port placed near the cutting surface of the tip for increased washing and cooling of the operative site. the chances of inadvertently perforating the crown of a tooth are reduced greatly. posts luted with resin cements such as Panavia fail to dislodge by ultrasonic vibration. BUC 1 and CPR 2D are examples of tips that fall into this category. The core buildup around the post should be removed before applying the vibratory tip. the length and type of the post. These tips are designed primarily to remove dentine and core material quickly and expeditiously before subjecting the root canal obstruction to vibratory or troughing procedures. If this method does not loosen and free the post then alternate methods must be used.28 M. and the type of core buildup. Now with the help of ultrasonic tips. the core portion is reduced and sculpted until it becomes an extension of the post itself [13].K. The inability to remove posts by vibration alone is dependent on many factors such as the type of luting agent. However. Iqbal / Dent Clin N Am 48 (2004) 19–34 are activated at the maximum intensity and moved circumferentially until the post loosens or dislodges. Troughing tips Troughing tips are used to create a sufficiently deep trough around posts to maximize the benefits of subsequently applied vibratory or extraction forces. . In some cases. The manufacturer cautions against placing these tips directly on ceramics because it may cause severe damage to the prosthesis. Therefore. In the past. Posts luted with zinc phosphate cement can be dislodged readily by ultrasonics because of microcrack formation in the cement [12].

10.K. which also is available with a diamond coating. . which are 20. and 27 mm long. These instruments are especially useful when removing long and thick prefabricated post systems (Fig. Fenton. Samuel Kratchman. and parallel sided to cut deep into the root without taking away too much dentine. the troughing is performed with instruments such as CPR 3D. (B) View of the trough produced around the lingual aspect of the post with the help of ultrasonic files. The initial troughing around a post can be performed with shorter tips such as diamondcoated CPR 2D or 3D. (Courtesy of Dr.) Initially. respectively. PA. These instruments are quite slender. The fact that these Fig. If the obstruction is located in the deeper part of a straight canal. 11). 24. These instruments are used in the coronal. respectively (Fig.M. and 25 mm in length. 20. 9. and at the same time provide maximum visibility under the microscope (Fig. These instruments are diamond coated and aggressively cut dentin along their lateral sides. and 8 (green) are used. The instruments not only remove cement that may be present around the post. Iqbal / Dent Clin N Am 48 (2004) 19–34 29 Fig. middle. but also remove a thin shelf of dentine around the perimeter of an obstruction. Ohio) or CT 4 tip (Sybron Endo). 9). and apical one third of root canals and their selection depends on the depth at which they need to be operated. 10). long. then titanium CPR tips 6 (red). which are 15. 4D. and 5D. can be used for this purpose. Exton. The BUC 3 (Obtura/Spartan. (A) CPR 6 is being used to trough between the post and the lingual wall of the root canal. 7 (blue).

which allows them to cut dentine as close to the obstruction as possible.K. Iqbal / Dent Clin N Am 48 (2004) 19–34 Fig. 11. threaded post associated with a failing root canal treatment. 13). and 8 are end cutting and only active at their tips.. that is. Therefore. subject to breakage. GG drills can be used only in the straight portions of the canal and are unable to . (B) Radiograph showing completion of root canal treatment after removal of the threaded post. 7. These tips most commonly fracture when inadvertently brought into contact with metallic objects such as posts. before troughing with these tips a collar of dentine must be exposed around obstructions that are embedded in root canals. at the same time. with the same amount of pressure used to avoid breaking the lead tip of a pencil. which are diamond coated and active along the sides of their tips. Texas). The instruments should be used with a light touch.30 M. Gates Glidden (GG) drills also can be used for this purpose. instruments are made of titanium alloys and have thin cross-sectional diameters makes them extremely flexible and vibrant. but. and a shelf of dentine is prepared around the obstruction (Fig. The instruments must be used at low intensities and always under the magnification provided by the microscope so as to not inadvertently contact any metallic obstruction. extreme caution needs to be taken when using these instruments. CPR tips 6. 12). The instruments are used sequentially to the coronal extent of the obstruction until the canal is enlarged sufficiently. 4D. Therefore. (A) Radiograph showing the presence of a long. and 5D. San Antonio. however. The collar or shelf of dentine can be prepared around the obstructions with the help of LightSpeed instruments (LightSpeed. The tips of these instruments are flattened with the help of a grinding stone (Fig. Inc. Unlike CPR tips 3D.

and 5D. and 8 can be used to create a trough around the instrument (see Fig. The NiTi files mainly break by either torsional fracture or flexural fatigue [15]. The use of NiTi rotary instruments has increased the incidence of file separation in endodontics. 7. the instrument usually gets forced into the root canal and. 15B). 4D. Even though these instruments are not tightly bound in dentine. retreatment becomes difficult when the coronal end of the instrument lies apical to the elbow of the curvature and cannot be seen with the help of the surgical operating microscope. CPR tips 6. Nevertheless. The fractured instruments usually are engaged into dentine along their whole lengths and at times may be difficult to remove. The tips are moved counterclockwise around the fractured instrument to disengage it from the surrounding dentine [14]. negotiate any curvatures in the root canals [13].K. once jammed. Drawing showing LightSpeed instruments flattened at their tips with the help of a grinding stone. 13D). These instruments do not exhibit any unwinding of flutes when observed under the operating microscope (see Fig. 14). In the former case. Once loosened. fatigue failure causes the instrument to fracture at the point of its maximum flexure. On the other hand. In addition to trephining around posts and removal of broken instruments and other intracanal obstructions. BUC 3. Iqbal / Dent Clin N Am 48 (2004) 19–34 31 Fig. the exposed part of the separated instrument can be grabbed and pulled out with one of the currently available extraction devices. they may be difficult to access because their coronal ends usually are located apical to the elbow of root curvature. In other instances. The procedure can be accomplished with CPR 3D. or ST21 Enac tips under the microscope so that the paste can be differentiated easily . 12. This type of failure is associated most often with an unwinding of flutes that can be recognized under the operating microscope (Fig. Once the shelf of dentine is prepared.M. 15A). ultrasonic instrumentation also can be used for eliminating brick-hard paste-type materials [16]. fractures at its weakest point. the instrument usually moves coronally and ‘‘jumps out’’ from the root canal (Fig.

K. . Iqbal / Dent Clin N Am 48 (2004) 19–34 Fig. (C) The arrow in the figure points toward a shelf of dentine that has been created around the separated instrument. a small-sized instrument is selected and carried down to the obstruction. The arrow in the figure points toward the approximation of a modified LightSpeed instrument and the root canal obstruction. (D ) The arrow indicates a trough created around the separated instrument with the help of ultrasonic tips. 13.32 M. (B) Instruments are used sequentially to enlarge the root canal space. (A) Initially.

15. Bekir Karabucak. the paste—depending on its color—appears as a white or pinkish dot. 14.) from the surrounding root canal dentine. Under the microscope. The instrument was removed easily with ultrasonic vibration. The CPR tips are used to eliminate it by following the dot to its apical extent. because the ultrasonic files are unable to negotiate curvatures and may lead to perforation of the root surface. no attempt should be made to remove paste materials around curves. This is done by depositing mineral Fig. . (A) Preoperative radiograph of a maxillary left first premolar shows a separated instrument in the palatal canal. no signs of unwinding of the flutes can be noticed. PA.K. However. Ultrasonic tips also can be used to help MTA flow precisely into place. Iqbal / Dent Clin N Am 48 (2004) 19–34 33 Fig. Philadelphia. (B) In case of flexure failure.M. (B) Postobturation radiograph. (A) Drawing of a NiTi instrument depicting unwinding of the flutes associated with a torsional failure. (Courtesy of Dr.

Microendodontics. [10] Johnson WT. Walker WA. J Endod 1994.41(3): 429–54. 42(1):92–9. 16(4):158–61. Boyer DB. Ahmed M.34 M. Evaluation of ultrasonic and sonic instruments for intraradicular post removal. Eliminating intracanal obstructions. Defects in rotary nickel-titanium files after clinical use. An experimental study of the removal of cemented dowel-retained cast cores by ultrasonic vibration. The impact of improved access and searching techniques on detection of the mesiolingual canal in maxillary molars. Nervo GJ. Available at: http://www. J Endod 1990. Effect of ultrasonic vibration on post removal in extracted human premolar teeth.obtura. J Endod 1997. Caputo AA.html. Palamara JE. J Endod 1989. Oral Health 1997. the use of ultrasonic instruments requires specialized knowledge and development of certain skills that may require training before use.28:100–2. Shibata T. J Endod 1987.22:287–9.15(2):82–3. Effect of ultrasonic vibration and various sealer and cement combinations on titanium post removal. Lumley PJ. Schindler WG. . Johnson WT. Peters DD. [6] Weller RN. Physical mechanisms governing the hydrodynamic response of an oscillating ultrasonic file. Lumley PJ. Iqbal / Dent Clin N Am 48 (2004) 19–34 trioxide aggregate (MTA) at a site (ie.K. Incidence and configuration of canal systems in the mesiobuccal root of maxillary first and second molars. Ishikiriama A. [5] Kulild JC. Tomomi I. Dent Clin North Am 1997. Seto BG.23:239–41.13(6):295–8. Sekine I. Leary JM. [3] Walmsley AD. [8] Buoncristiani J.87(8): 19–21.27(1): 13–7.20:486–9. Messer HH. [2] Waplington M. Shunji G. J Endod 1996. [7] Instructions for use. Fenton (MO): Spartan Marketing Group. Int Endod J 1994. 23–4. Accessed on January 21. Walton RE. Oral Surg Oral Med Oral Pathol 1976.22:487–8. Int Endod J 1995.27(4):197–207. Hartwell GR. [14] Ruddle C. Ultrasonic disinfection of the root canal.com/bucaccesstips. Ueno AH. Endod Dent Traumatol 2000. [11] Yoshida T. [15] Sattapan B. Murchison DF. [9] Berbert A. 2004. Summary The use of ultrasonic instruments has revolutionized the art of endodontic retreatment. Filho MT. References [1] Martin H. Micro-endodontic nonsurgical retreatment. Removal of hard paste fillings from the root canal by ultrasonic instrumentation. J Endod 2000. [13] Ruddle CJ. An in vitro investigation into the cutting action of ultrasonic radicular access preparation instruments. [16] Jeng HW. The influence of ultrasound in removing intraradicular posts.16(7):311–7. J Endod 1996. However. Breakage of ultrasonic root-end preparation tips. Bramante CM. [4] Roy RA. These instruments have multiple uses and have become an integral part of the endodontic armamentarium. ElDeeb ME. Crum LA. perforation) and then vibrating it with an activated ultrasonic tip until it flows evenly into the defect. J Endod 2001. Blunt L. BUCTM non-surgical ultrasonic endodontic instruments. [12] Bergeron BE.26(3):161–5.

1016/j. School of Dentistry. Seodaemun-gu. Frequently. DDS. even with multidirected angles. which alters the position of the minor diameter. EALs are particularly useful when the apical portion of the canal system is obscured by certain anatomic structures. the CDJ and apical constricture do not always coincide.005 .2003. in order for the exit to be verified. Indeed. DDS. doi:10. It also is referred to as the minor diameter or the apical constricture. is recommended [1. 134 Shinchon-dong. 0011-8532/04/$ .2]. which may be higher with conventional radiographic measurements. EALs help to reduce the treatment time and the radiation dose. However. particularly in senile teeth as a result of cementum deposition. E-mail address: sjlee@yumc. where it is easy to clean and shape or obturate the canal. Lee). excessive bone density. The electronic apex locator (EAL) machine has attracted a great deal of attention because it operates on the basis of the electrical impedance rather than by a visual inspection. The EAL is one of the breakthroughs that brought electronic science into the traditionally empirical endodontic practice. the zygomatic arch. The cemento-dentinal junction (CDJ). MS* Department of Conservative Dentistry. The apical constricture of the root also does not coincide with the anatomic apex. tori.yonsei. setting the apical constricture as the apical limit of the working length.cden. All rights reserved.kr (S-J. It is deviated linguo-buccally or mesio-distally from the root [3–5]. In addition.see front matter Ó 2004 Elsevier Inc. MSD. Korea Locating the appropriate apical position always has been a challenge in clinical endodontics.Dent Clin N Am 48 (2004) 35–54 Electronic apex locator Euiseong Kim. is the most ideal physiologic apical limit of the working length. Therefore. it is very difficult to locate accurately the position of the apical foramen using only roentgenograms.ac. a file needs to be inserted into the canal to force it through the apical foramen. Seoul 120-752. where the pulp tissue changes into the apical tissue. PhD Seung-Jong Lee.10. such as impacted teeth. overlapping roots. Yonsei University. EALs * Corresponding author. If the exit deviates bucco-lingually. or shallow palatal vaults. EALs currently are being used to determine the working length as an important adjunct to radiography.

One of the most widely used apex locators in the 1970s and 1980s. are more compact. Kim. newer units such as the Neosono (Amadent. New York. New Jersey) and many other resistance-type apex locators became available. Little was done with this idea until 1942 when Suzuki [7] reported a device that measured the electrical resistance between the periodontal ligament and the oral mucosa.) A new apex locator. the Sono-Explorer (Union Broach. was developed in the late 1980s to improve the resistance-type apex locators. but rather a physical principle. New York). Inoue [10] reported a modification that incorporated the use of an audiometric component that permitted the device to relate the canal depths to the operator via low-frequency audible sounds. these resistance-type EALs often yield inaccurate results when electrolytes. the electrical resistance between the root canal instrument inserted into a root canal and an electrode applied to the oral mucous membrane registered a consistent value of approximately 6. By 1975. and suggests the correct use of an apex locator for a better canal length measurement. a question also was raised as to whether this mechanism could be applied to the real root canal with various anatomical complications [16]. History of EALs Traditional-type apex locators (resistance or impedance type) In 1918. S-J.36 E. Huang [9] reported that this principle is not a biologic characteristic. when a canal is thought of as being a long hollow tube [15].34]. Cluster [6] first put forth the idea that the root canal length could be determined by using the electrical conductance. These principles were not examined further until Sunada [8] performed a series of experiments on patients and reported that the electrical resistance between the mucous membrane and the periodontium was consistent.43. excessive moisture. was developed using this modification. the types of electronic working mechanism. However. such as pulp vitality [20. the impedance type. Cherry Hill. This article reviews the history and the working mechanism of the currently available EALs. .5 Kx. some questions still exist as to whether the accuracy of EAL can be affected by the different types of electrolytes [19. and are easier to operate [11]. or excessive hemorrhage are present in the canals [12–14]. vital pulp tissue. exudates. or foramen size [51.31. which is the narrowest portion of the canal where the impedance changes drastically.52]. regardless of the age of the patients or the shape and type of the teeth. They have improved circuitry. The impedance-type EAL uses the electronic mechanism that the highest impedance is at the apical constricture.45]. and the conditions of the root canal. (The effect of the canal contents on the accuracy of an EAL is discussed later in this article. However. In 1987. Lee / Dent Clin N Am 48 (2004) 35–54 were reported to be an accurate and reproducible method as the newest thirdgeneration type and can acknowledge a root perforation. However. He discovered that in dogs.

it is unnecessary to calibrate this device each time because the microprocessor automatically controls the calculated quotient to have a relationship with the file position and the digital read out when the file is inserted into the coronal portion of the canal [22].. Tustin. Orange. 8 kHz). Frequency-dependent apex locators The newest type of EAL was introduced in the early 1990s in an effort to obtain a more accurate canal length measurement in various canal circumstances. but only a single frequency at a time. The major advantage of this device is that it works well regardless of the presence of pus or electroconductive environments in the canal [19. The AFA (all fluids allowed) Apex Finder Model 7005 (Analytic Endodontics.20]. a disadvantage is that a calibration needs to be done each time. In addition. the difference becomes greater and shows the greatest value at the apical constricture. However. 2. which was difficult to use in narrow canals. This quotient is barely affected by the electrical conditions inside the canal [14]. in addition the Teflon peeled off in curved canals. allowing for a measurement of that location. and expresses this quotient in terms of the position of the file inside the canal. Akron. In addition. and the calibration had to be done before using the device [17]. which uses five different frequencies (0. which was the basic working mechanism of the Root ZX (J. Lee / Dent Clin N Am 48 (2004) 35–54 37 The Endocator (Hygienic Corporation. Another disadvantage with this device was that the patient sometimes felt uncomfortable due to the high current used. In 1990. As the file moves toward the apex.. Japan).5. S-J. The use of a single-frequency signal eliminates the need for filters that separate the different frequencies of the complex signal. It works by comparing the difference in impedances using the relative value of two alternating currents at frequencies of 1 and 5 kHz. Rishon Lezion. The manufacturers . Yamashita [18] reported on a device that calculated the difference between two impedances from two different frequencies. The Bingo 1020 (Forum Engineering Technologies. Kim. Morita Corp. Kobayashi et al [21] reported on the ‘‘ratio method’’ for measuring the root canal length. This device used a large file coated with Teflon.4 kHz and 8 kHz at the same time. California) [21]. This device was reported to be quite accurate in various conditions [23–25]. calculates the quotient of the impedances. which were generated with composite sine wave current sources. Ohio) was an example of an impedance-type apex locator. 4. the position of the file tip in the Bingo 1020 is calculated based on the measurements of the root mean square value of the signal. 400 Hz and 8 kHz. In 1991.E. 1. It uses more advanced technology and measures the impedance difference between the two frequencies or the ratio of two electrical impedances. Tokyo. This device measures the impedances of 0. Israel) uses two separate frequencies. California) is another type of frequency-dependent EAL. and was marketed as the Endex (Osada Electric Co.

With traditional-type EALs. Devices that combine an apex locator and an electrical pulp tester also have been marketed. Apex locators with other functions EALs with additional functions were developed in the late 1990s. the accuracy depends more on the individual operator’s skill and the various canal conditions. Recently. large sized rotary files had a tendency to slow down the rpm speed. Kim. this device allows the file to rotate back out of the canal.). However. However. which is a combination of an ultrasonic hand piece and a Root ZX.16. was designed to prevent overinstrumentation by stopping the ultrasonic vibration when the file reaches the required location. When the file has reached the required location.) was introduced to the market. Morita Corp. Lee / Dent Clin N Am 48 (2004) 35–54 claim that a combination of these two techniques increases the measurement accuracy [37]. thereby preventing overinstrumentation. it has the disadvantage that the number of rpm reduces with increasing pressure due to the limitation of the rechargeable battery. it also prevents the fracture of the Ni-Ti rotary file by allowing the file to rotate back out if it goes over the set auto-torque-reverse mechanism threshold of 40 to 80 g/cm [26]. California). Morita Corp. the accuracy of traditional EALs was inconsistent and affected by many variables [9. One advantage of the Dentport ZX is that it has an auto apical slow-down function—when the rotary file reaches the apical constricture. it appears that the file was easily controlled when using the hand piece at 50 to 800 rpm and a torque ranging from 30 to 500 g/cm.) is a Root ZX with a cordless rechargeable electric hand piece that uses a Ni-Ti rotary file with 260 to 280 revolutions per minute (rpm) [26].27–29]. Both functions can be used by exchanging the back cover. The Dentaport ZX is comprised of two modules—the Root ZX module and the Tri Auto ZX module. Morita Corp. One of the alleged advantages of frequency- . This unique function appears to be quite useful as the Ni-Ti rotary file becomes more popular. In addition. One example is the Elements Diagnostic Unit (SybronEndo. the Dentport ZX (J. In addition. The Tri Auto ZX (J. the rpm slows down allowing for a careful sculpture of the apical portion. based on our clinical experience. further research is needed to determine the effect of a file fracture when the rpm changes inside the canal. It has a separate monitor called a ‘‘Satellite.38 E. Orange. possibly due to the low torque setting.’’ which can be clipped to the patient’s napkin or other surface. General accuracy of frequency-dependent EALs Before the era of frequency-dependent EALs. S-J. such as the existence of electroconductive solution. The Solfy ZX (J. In the Tri Auto ZX module.

85 to 0. the RCM Mark II (Evident Dental Co. Goof Co.578 mm). California) with a traditional-type EAL (Odontometer.42.4%). The mean of the absolute values of the deviations from the apical constriction for the apex locator (0. NaOCl. A similar study [30] compared the Apit (Osada Electric Co.5-mm clinical tolerance whereas 70% was in the . Ltd. they found that the Root ZX located the apical foramen precisely in 17 canals (65. The average deviation of the Apit was 0.5 mm beyond the foramen were used as the acceptable range. was short in 1 canal (3..64% of 185 moist canals. Mayeda [31] reported that all measurements were within a narrow range (0. L. Vajrabhaya and Tepmongkol [24] tested the Root ZX under clinical conditions using vital and nonvital pulp. Similar results were obtained when the Endex was tested on a human cadaver [33]. Most of the EAL measurements were compared with the actual tooth length.. According to recent publications [34. In another in vivo experiment using vital or necrotic pulps. the accuracy was 96.7%) was higher than that of the RCM Mark II (43.8%). S-J. The overall accuracy of the Endex (71.5-mm clinical tolerance.57]. even under different wet canal conditions. Shabahang et al [23] examined 26 root canals of the vital teeth to evaluate the performance of the Root ZX.5%). In vivo studies Arora and Gulabivala [20] compared the accuracy of Endex in the presence of vital and nonvital pulp tissue and commonly encountered canal electrolytes (pus. They reported that the Endex located the apical constriction accurately within a 0. Several experiments have used radiographic lengths as a reference.50 mm).36 mm (range = 0. London. whereas the average deviation of the Odontometer was 0.86 mm to 0. After measuring the distance between the tip of the endodontic file and the apical foramen. with an 88% accuracy at a 0. United Kingdom)..35 to 2.E.5-mm clinical tolerance when measured from the apical foramen.45 mm) with a 73% accuracy at a 0. Los Angeles.2% at a 0.5-mm clinical tolerance.65 mm) with a 93% accuracy at a 0.5-mm clinical tolerance. The Apit tended to yield more reliable results than did the Odontometer. Frank and Torabinejad [32] compared the Endex with radiographic measurements. A number of experiments were conducted using both in in vivo and in vitro models (Table 1). at a 0. water) with that of a traditional-resistance type EAL. the accuracy of frequency-dependent EALs is much higher than that of traditional-type EALs (simple-resistance type or impedance type).14 mm (range = 0. However.5-mm clinical tolerance. Kim.. Lee / Dent Clin N Am 48 (2004) 35–54 39 dependent EALs is that it operates accurately. This difference was statistically significant (P \ 0. Eighty-nine percent of the EAL was within a 0. Ho¨rrsholm.001).259 mm) was significantly lower than that for the radiographic method (0. and was overextended in 8 canals (30. Denmark) in vivo.5-mm clinical tolerance in 89. and reported 100% accuracy when less than 1 mm from the apical foramen and less than 0.8%).

Lee / Dent Clin N Am 48 (2004) 35–54 Reference . Accuracya 89.75% 87.5 mm.6% 87.40 Table 1 Accuracy of frequency-dependent apex locators Year Study type EAL N (canals) Comparison Frank et al [32] Mayeda [31] Felippe and Soares [52] Arora and Gulabivala [20] Czerw et al [41] Pratten and McDonald [33] Lauper et al [30] Shabahang et al [23] Vajrabhaya and Tepmongkol [24] Ounsi [59] Dunlap et al [50] Pagavino et al [25] Ibarrola et al [58] Ounsi and Naaman [49] Lee et al [47] Meares and Steiman [42] Neekoofar et al [57] Pommer et al [34] Kielbassa et al [40] 1993 1993 1994 1995 1995 1996 1996 1996 1997 1998 1998 1998 1999 1999 2002 2002 2002 2002 2003 Patient—radiograph Patient—extract Extracted teeth Patient—extract Extracted teeth Cadaver—extract Patient—extract Patient—extract Patient—extract Extracted teeth Patient—extract Patient—extract Extracted teethb Extracted teeth Patient—extract Extracted teeth Extracted teethc Patient—radiograph Patient—extracte Endex Endex Endex Endex Root ZX Endex Apit Root ZX Root ZX Endex Root ZX Root ZX Root ZX Root ZX Newly designed Root ZX Neosono Ultima EZ AFA apex finder Root ZX 185 33 350 61 30 27 30 26 20 34 34 29 16 36 31 40 54 152 105 Radiographic apex Apical foramen—M Apical foramen—D Apical foramen—M Apical foramen—D apical Constriction—M Apical foramen—M Apical foramen—M Apical foramen—M Apical foramen—D apical Constriction—M Apical foramen—SEM Apical constriction—M Major diameter—D CDJ—M Apical foramen—D Apical foramen—D Radiographic apex Minor diameter—D Abbreviations: D.56% 82. b Preflared canal.2% 100% 84. e Primary teeth.7% 100% 89% 93% 96. d Radiographic apex 1  0.5% 71. Kim.5 mm. M.5% 84. direct view (magnifier).5%d 64. SEM. S-J. microscope.3% 82. c Ni-Ti file was used. scanning electron microscope. a Within 0. f Within 1 mm.8%f E.9% 96.72 92% 83% 94.4% 85.

6% and 61.5-mm clinical tolerance of the anatomic apex. Kaufman et al [37] compared this new frequency-dependent EAL with the Root ZX and found that the Bingo 1020 was consistently more accurate than was the Root ZX.E. whereas in the group that used the EAL.5-mm clinical tolerance. measurements attained within this tolerance were considered to be highly accurate. Kim. no retake radiographs were required. although both units measured the tooth length with great accuracy.5-mm clinical tolerance. In contrast. only 15 (60%) teeth tested using radiographs alone were within the 0. S-J.5-mm clinical tolerance. El Ayouti et al [36] reported that the electronic working length measured by the Root ZX reduced the percentage of overestimation to 21% compared with radiograph only.5 mm of a point 1. Brunton et al [35] performed an in vitro experiment to determine whether the use of an EAL (Analytic AFA) could reduce radiograph exposure.4% for the conventional and digital radiologic methods. The EAL was extremely accurate in locating the apical foramen with all the teeth tested within a 0. 14 retake radiographs were required to determine the working length. The operation is based on the principle of the relative difference or a quotient of two or more impedances generated at each different frequency. the Bingo 1020 was introduced to dental practice.5% of 350 human teeth located the apical foramen at a 0. The 0. Therefore. Recently. versus 50. In vitro studies Felippe and Soares [52] tested the Apit in an isotonic saline container model and found that 96.40] prefer the 1-mm range.8% of cases with a 0. In the group that did not use the EAL (25 teeth). The electronic method was satisfactory in 67. However. The recently marketed AFA Apex Finder [34] also showed a high accuracy in clinical situations. in 86% of the roots evaluated. some authors [39. the file tip position (as indicated by the Apex Finder) was located within 0. Digital radiography was compared with the Apit EM-S3 in a wellcontrolled in vitro model [38]. an error tolerance of 1 mm can be deemed clinically acceptable. respectively. Lee / Dent Clin N Am 48 (2004) 35–54 41 radiographic length.5-mm clinical tolerance is considered to be the strictest acceptable range. Although . Accuracy of frequency-dependent EALs in different electrolytes A major advantage of frequency-dependent EALs is that they operate even with a high electroconducting irrigant such as sodium hypochlorite. Shabahang et al [23] reported that because root canals frequently lack a well-delineated apical constriction. The authors [38] concluded that none of the techniques were totally satisfactory in establishing the true working length.0 mm short of the radiographic apex. When compared with radiographic measurements.

000 epinephrine. RC Prep (Premier Dental Product. 2% lidocaine with 1:100. such as hemorrhage. Kim. To determine whether the concentration of sodium hypochlorite influenced the accuracy of the Root ZX. several questions as to whether the different electrolytes in the canal or the size of the root canal affect the accuracy still remain. and Peridex (Zila Pharmaceuticals. 5. 3% hydrogen peroxide. The authors [42] suggested that the Root ZX was not adversely affected by the presence of sodium hypochlorite. and the pulpal and periapical conditions. Jenkins et al [43] evaluated the accuracy of the Root ZX in vitro in the presence of a variety of endodontic irrigants. No significant differences were found between the experimental groups.. the measurements obtained in the dried canals presented a variety of inconsistent and nonpredictable results. Meares and Steiman [42] flushed the canal with 2. exudate. The authors [32] explained that this was due most likely to the operators not drying the canals completely. saline. Frank and Torabinejad [32] compared the Endex measurements with the radiographic measurements in 185 root canal lengths. Several studies warned that a high electroconductive solution might affect the accuracy. the Root ZX showed no difference between the distilled water and dry canal. it showed a 90% accuracy in the smaller foramens but only a 57% accuracy was observed in the larger apical foramens. the type of moisture.64% of moist canals.25% sodium hypochlorite and the measurements from the in vitro model then were compared with the actual canal lengths. irrigant fluids. liquid ethylenediaminetetraacetic acid (EDTA). The accuracy of the Endex at the 0.25% sodium hypochlorite.125% and 5. However. The presence of an apical radiolucency or a restoration. Philadelphia. the length of the canal. They found that the Endex located the apical constriction accurately within the 0. .5-mm clinical tolerance in 89. or sodium hypochlorite. S-J. Many studies showed promising results with this third-generation device. When the Endex was used in the dry canals. When the dried canal was compared with a distilled water–filled canal [41] in an in vitro saline–gelatin model. In contrast. did not influence the results. Fouad [19] compared the accuracy of the Endex with that of the traditional-type EALs with regard to the effects of the fluids in the canal and the variation in the foramen size. most of these studies focused on the Endex (Apit) and the Root ZX. there is still a concern as to whether high electroconductive irrigants such as blood.42 E. Lee / Dent Clin N Am 48 (2004) 35–54 frequency-dependent EALs enhance the measurement accuracy. Pennsylvania).5-mm clinical tolerance was 73% in the smaller apical foramens and 57% in the larger foramens. and sodium hypochlorite can affect the accuracy of the EAL performance. The author [19] suggested that the complete drying of the canal is not likely to be achieved clinically because some degree of moisture is bound to be present in the canals due to the hydration of dentin from the surrounding periodontium or as a result of the incomplete drying using the paper point. a local anesthetic solution. Inc.

Kim et al [45] reported that there were tendencies toward a short measurement in a high electroconductive solution such as NaOCl. whereas longer measurements were in the lower electroconductive solution. and 5.54 mm to 0.1% to 91. such as NaOCl. than saline [28]. 14.33 mm to 0. NaOCl. the different electroconductivities somehow affect the EAL measurement. normal saline. From a total of 45 root canals examined in each solution. they developed a new circuit that could automatically compensate for the voltage differences in the different irrigating solutions. whereas H2O2 was much lower (50 times). the largest deviation from the actual canal length was obtained with NaOCl.2% to 100%.45% EDTA sodium solution. Each irrigant . NaOCl was much higher (10 times). A higher prediction error was apparent for the more conductive solutions. the increased variance of this irrigant should be considered. No significant difference was noted in the prediction error at different frequencies (P > 0. 70% isopropyl alcohol. regardless of the irrigants. Kim. S-J. The authors [43] stated that considering the widespread utility of NaOCl as an intracanal irrigant.E. To minimize the measurement errors. It was speculated that the change in the electroconductivity shifts the quotient curve of the frequency ratio. the errors were significantly reduced. They evaluated the impedance change at different locations in the root canal system with various frequencies and canal irrigants and calculated the prediction error when the EAL was used in these various conditions in vivo.02). When the electrical resistance of the most frequently used irrigants were measured. Union Broach). The measured lengths were generally longer in H2O2 and shorter in NaOCl compared with saline.01 mm in the NaOCl solution in an in vitro study. respectively. As a result of this compensation.5-mm clinical tolerance were improved for the H2O2 and NaOCl solutions from 71. The impedance ratio of the two different frequencies represented the position of the file. the distributions of the voltage differences and the measurement errors were obtained. Lee / Dent Clin N Am 48 (2004) 35–54 43 Phoenix. Arizona). Briefly. These results suggest that although the working mechanism is unclear. the impedance ratios and voltage differences were obtained from the three different irrigating solutions (saline. the prediction error was significant with respect to the different irrigants (RC Prep. on average from 0.31 mm.1% and from 82. However.25% NaOCl) (P \ 0. Pilot and Pitts [44] conducted a sophisticated study on the prediction error of the EAL (Sono Explorer Mark IV.18 mm in the H2O2 solution and from 0. However. These tendencies were expressed by a voltage difference. The accuracies based on a 0. The voltage differences measured were generally larger in H2O2 and smaller in NaOCl when compared with saline. The results showed that the Root ZX reliably measured the canal lengths to within 0. whereas the voltage difference represented the status of the fluid in the root canal.05). using the conventional impedance ratio method with two sinusoidal waves (0.5 and 10 kHz). and H2O2) in an extracted tooth model.

The operation manual of the Root ZX [48] recommends that the file be . Nam et al [46] reported that the mean error was 0. The measurement accuracies were 94% (29/31) from the major foramen and 92% (24/26) from the CDJ with a 0. There were no differences between either the smaller (\#25) and larger apical foramens (#25).27 mm from the constriction point.’’ which then was added or subtracted to the impedance ratio for compensation. The average distance from the detectable 26 CDJ samples was 0. 1.46 mm. Therefore. The compensating value was determined in proportion to the difference between the measured voltage difference and either the ‘‘upper limit (UL)’’ or ‘‘lower limit (LL). respectively.98 to 0. Lee / Dent Clin N Am 48 (2004) 35–54 Fig.44 E. S-J. Measurements can change as a result of different measuring methods such as what point of the unit the operator uses as a reference and whether to use the major diameter or the constriction point from the EAL reading.2% of the measurements were within the clinical tolerance of 0.28 to 0.5 mm tolerance.14  0. or the vital and nonvital pulps.18 mm with a range of 0. was classified statistically using a Bayes linear classifier (Fig. When this compensation circuit was tested in clinical situations.5 mm. Distributions of voltage difference versus error for the three solutions in the canal. the file would go deeper in a higher electroconductive condition such as NaOCl. 1). whereas it would go less deep in a lower electroconductive condition such as H2O2. and 95. the average distance of the measurements was 0. during the actual determination of the working length. ‘‘LL’’ and ‘‘UL’’ are decision boundaries that classify a smaller voltage difference solution (NaOCl) and a larger voltage difference solution (H2O2) for 45 extracted root canals (in vitro). Kim. Lee et al [47] also reported promising results from the compensation circuit. When the distances from the major foramen and CDJ were measured.13 mm from the major foramen with a range of 0.65 mm.

5 mark.0 mark [25.50 mm). longer readings occurred with the Endex (80. the accuracy would fall to 70% for vital tissue and 69% for necrotic tissue. The clinical accuracy was 82. The authors of this study [25] recommended the withdrawal of the instrument by approximately 0. to place the filling material above the apical seat. When the apex is reached. they discouraged the use of the 0.85 mm. and another one third were right at the apical foramen.5 mm. The results indicated that the accuracy of all measurements were within a narrow range (0. In general. The . several authors have questioned using the 0. the file tip protruded beyond the apical foramen with a range between 0. the mean value of the difference between the EAL and actual length was outside of the 0.5 and APEX marks.12 mm and 0.5 mark as advised by the manufacturer.3%) than with the RCM Mark II (50. most of the measurements would actually be beyond the apical constriction. the mean value was within this tolerance range (84. Kim.5 or 1. In an in vivo study with a newly designed compensation circuit. The file then is advanced with a slow clockwise turn until the word ‘‘APEX’’ begins to flash.5 to 1 mm be subtracted from the EAL measurements. with 88% at the 0. However. as indicated by the ‘‘0.49].5-mm clinical tolerance from the major apical foramen.5’’ mark on the meter.72%). when the APEX mark was selected. Some recommend that the APEX mark be used instead of the 0. The manual also advises that 0. and the measurement is then read. The results showed that if the 0. Lee / Dent Clin N Am 48 (2004) 35–54 45 inserted until the meter reads 0.8%).5 to 1 mm to avoid overpreparation. the RCM Mark II. Because one third of the measurements were long. and suggested that the canal length be measured when the ‘‘APEX’’ mark is reached [49]. the file is turned slowly counterclockwise until the meter reads 0. However. However. In 28 out of 29 examined teeth. S-J. Therefore. if the readings from the apical constriction instead of the major foramen were counted. Lee et al [47] reported that most measurements (19/25) were beyond the CDJ. water) with that of a traditional-type EAL. NaOCl. Arora and Gulabivala [20] compared the accuracy of the Endex in the presence of vital and nonvital pulp tissue and commonly encountered canal electrolytes (pus. Another study [25] evaluated the accuracy of the Root ZX in two foramen locations: with the foramen at the end of the root tip and with the foramen deviated from the main axis.5 mm.75% with a tolerance level of 0. Similar results were reported for the Endex. Mayeda [31] found that the Endex consistently located a point that was closer to the major diameter than the apical constriction.5 mark was selected.5-mm clinical tolerance (50%).E. The authors [20] suggested that the manufacturer’s calibration of the Endex resulted in an overinstrumentation of the canal length.5 mm when the measurements were read at the APEX mark.86 mm to 0. Ounsi and Naaman [49] performed an in vitro experiment to evaluate the performance of the Root ZX at two different settings: the 0.

and 97% of the major foramen and 92% of the CDJ measurements were within 2 SDs. nonvital group. There was no statistical difference in the measurements between the vital and necrotic canals (vital group. which would cause a lower accuracy. However. the apical constriction might be altered or even nonexistent with no viable periodontal tissue to respond to the EAL. the question as to how the measurements could be reproduced consistently is more important than where to read the measurements.51 mm in the nonvital . Similar results were supported by succeeding investigations with the Root ZX [24] and the newly designed circuit [47]. whereas the readings for necrotic pulp were substantially lower (45.057.35 mm. In this study [47].32 mm. both vital and necrotic.21 mm in the vital canals and 0.11. if the machine pointing is consistent and the position and the average distance between the file tip and the true CDJ are known. When the influence of root canal status on the determination of root canal length using the AFA Apex Finder in vital and necrotic canals was compared. The authors [34] suggested that in necrotic cases with inflammatory root resorption. S-J.5. the authors used the SDs to evaluate the measurement consistency.5-mm clinical tolerance.05) [34].86 mm to 0. In a study using the Root ZX. The mean distance from the constriction was 0. There have been several disagreements on the effect of pulpal vitality on the accuracy of EAL.46 E. Arora and Gulabivala [20] reported that the Endex provided a better reading in vital tissues (88. then an accurate length can be obtained by subtracting the average distance directly from the machine reading.71 to 0. Kim.86 to 0. 33 teeth. Effect of pulpal vitality on the accuracy of EAL Most studies [24. Eighty-one percent of the major foramen and 65% of the CDJ measurements were within 1 SD. mean ¼ 0. these results showed that the measurements from the major foramen were more consistent than were those from the CDJ.9%). the results showed a higher accuracy for determining the apical constriction in vital canals (93. Dunlap et al [50] compared the canal length in vital and necrotic canals. mean ¼ 0.4%) within a 0. vital or necrotic) makes a difference in the determination. Lee / Dent Clin N Am 48 (2004) 35–54 reason for this was attributed to the fact that the machine reads the largest gradient of the impedance ratio at the point where the periodontal ligaments meet.9%) than in necrotic canals (76.5-mm clinical tolerance. range ¼ 0. and this difference was statistically significant (P  0. Again. were measured using the Endex apex locator and then were radiographed. The results indicated that all the measurements were within a narrow range (0.47] have reported that pulpal vitality does not affect EAL accuracy.50 mm).31. SD ¼ 0. Mayeda et al [31] conducted a study to determine whether the pulp status (ie. The authors [47] suggested that SDs be used to test the accuracy along with the average discrepancy with the 0. In this in vivo study. No matter where the machine points.6%).43). range ¼ 0. SD ¼ 0.

Lee et al [47] reported that there were no differences between the smaller (\#25) and larger apical foramens (#25). The initial canal length (IL) was measured using the EAL by negotiating a size 10 file to the apical constriction. no statistical difference was found.5 mm different from the results obtained with the #15 files. The authors also speculated that apical resorption by the longstanding periapical radiolucency may have resulted in the destruction of the apical constriction. The length of the enlarged canals was measured using small-sized files and large files matching the canal diameter. Effect of foramen size on the accuracy of EAL In general. FL-60.E. 52. It was conceived that these periapical radiolucencies lacked a periodontal ligament and the periapical bone may have caused the abnormally long reading. In an in vitro experiment [52]. However. S-J. The authors [39] also reported that there were differences between the operator’s measurement abilities. which were taken with a #15 file. Nguyen et al [51] conducted an in vitro experiment to observe the effect on the measurement of the relative diameters of the file and the root canal using the Root ZX. Effect of resorption on the accuracy of EAL The use of EALs in apical resorption is under question because of the possible destruction of the apical constricture and the loss of the surrounding periodontal tissue. were compared with the EAL lengths obtained using the size comparable to the diameter of the root canal. Differences between the FL-10.7% of cases with a 0. the results with the larger files were the same as or less than 0. suggesting . Lee / Dent Clin N Am 48 (2004) 35–54 47 canals. and IL were similar. In all the teeth measured. and the final length (FL) measurements then were obtained using a size 10 file and a size 60 file.5-mm error beyond the constriction. Two necrotic pulps with a periapical radiolucency measured greater than 1.5% of the nonvital readings of the coronal or right at the apical constriction were measured.9% of the vital versus 23. The actual lengths. Goldberg et al [39] conducted an experiment to evaluate the accuracy of the Root ZX apex locator in determining the working length in teeth with 50 simulated apical root resorptions. there is a consensus that the file size does not affect the accuracy of EALs. The measurements were accurate in 62. the Apit also was used to evaluate the possible influence of the size of the instrument on the measurements.5-mm clinical tolerance when compared with direct visual measurements. When the initial file sizes were grouped according to the file size #25. The position of the file tip was observed histomorphometrically after the apical 4 mm of the canal was exposed by grinding the buccal aspect of the root. The canal was enlarged to size 60 with the rotary files. Kim.

Therefore. Detection of root perforation The early detection and immediate treatment of an iatrogenic perforation is most important for making a good prognosis [54]. Radiographic detection often hinders the existence of the perforation. and was preferred over the radiographic method. but in vivo. but this does not appear to be a problem. which are in the process of physiologic resorption. Effects of different metal types The question as to whether different types of metal can affect the accuracy of EALs has been raised. Nekoofar et al [57] evaluated the accuracy of the Neosono Ultima EZ (Amadenat) using two different types of metal: nickel-titanium and stainless . However. where the tip of the file ended 0. However.48 E. S-J. comfortable. Lee / Dent Clin N Am 48 (2004) 35–54 that the accuracy of the EAL in apical resorption may depend more on the operator’s experience. and the clinical conditions did not influence these results. Kim. They reported that the Root ZX had an accuracy that was similar to the actual length and the radiograph film. and accurate. the root canal type. Kaufman et al [56] compared the abilities of the Root ZX.06 mm to 0. conventional methods are not always applicable because the apical aperture is exposed to continuous and sometimes irregular resorption. all the tested EALs were clinically acceptable. with a tendency to slightly underestimate the root canal length just short (average ¼ 0. provides a great challenge to clinicians. The tooth. In these instances. Shabahang et al [23] reported that the Root ZX could locate the root end consistently. it is even more imperative to minimize the periapical damage to protect the succedaneous tooth bud. even with the resorption lacunae.98 mm) of the apex.60 mm short of the external outline of the root surface. When tested on 30 extracted human teeth in vitro. They also stated that the use of the Root ZX was quick. and Sono Explorer Mark II in detecting a root perforation. They reported that the device had a sufficient accuracy. Katz et al [53] tested the Root ZX in extracted teeth to determine whether this device could detect the tooth length in mature primary teeth that already had a different degree of root resorption. Kielbassa et al [40] conducted a similar study using the Root ZX. Accuracy in primary teeth The location of the actual apical foramen in the primary teeth. Apit III (Endex). the use of an EAL for making an early detection of a root perforation appears to be very effective. particularly when it occurs bucco-lingually [55]. the status of the periapex.

which leaves a thin wall at the coronal part of the dentin. S-J. 2A). a larger subtraction for a larger-sized foramen). However. A straightening of the curved canal can be another cause. We tend to trust EALs more when there is a stable electronic sign with reasonably controlled exudates and without any metallic restorations. . Kim. A file size that fits snuggly inside the apical canal is recommended. When EALs are used to verify the final working length. or a wide-open apex—a comparison of the EAL reading with the radiograph is strongly recommended. Lee / Dent Clin N Am 48 (2004) 35–54 49 steel. When the final EAL is used in a dried canal situation. EALs were useful in confirming the working length not only during the endodontic procedure but also in the final working immediately before the obturation. severely undermined caries. the unit will show an apex sign. Clinical suggestions Conventional radiograph still is needed Recent publications regarding frequency-dependent EALs appear to agree that EALs are more reliable than is conventional radiography.5 to 1 mm. Working length is changing continuously The working length changes constantly throughout the root canal treatment. the following things should be considered. breaking the apical constriction and creating an oval-shaped exit. EALs only provide the electronic impedance and not the canal shape. This may occur more frequently because the use of a rotary instrument is increasing in the endodontic practice. a radiograph still is mandatory in an endodontic procedure. and there was no statistically significant difference.E. depending on the size of the apical foramen (usually. severe exudation. where the meter sign of the EAL drops sharply to the APEX mark. Care needs to be taken so as not to break the apical seat or the remaining thin dentin wall. During the canal preparation procedure. In this case. Whether to trust EALs or radiography depends on how familiar the operator is with each method. the file position may become directly in contact with the apical soft tissue. First. Besides. 2B) than the initial working length (Fig. when the sign is unstable—particularly with metallic restorations. As the file tip touches the most coronal margin of the oval exit. We measured the changes in the working lengths between before and after canal shaping from 5000 root canals using frequency-dependent EAL and showed that there were some changes in the working lengths (Table 2). thereby measuring a shorter length (Fig. To obtain anatomic information of the roots and canals. the file inadvertently may go beyond the apical foramen. the apical area may become too enlarged leaving an extremely or stripped thin dentin wall. The accuracy of the nickel-titanium and stainless steel was 94% and 91%. respectively. it is advised to subtract 0.

Unstable electronic signal with rapid wandering signs An unstable electronic signal with rapid wandering signs is the most frequent malfunction of an EAL and occurs most frequently when the file touches the metallic restorations or when there is a cervical leak through the subgingival caries.3 0. As the file tip touches the most coronal margin of the oval exit.4 0.50 E.3 0.2 0.4 0. Table 2 Difference of the working lengths between before and after canal shaping Root Upper Upper Upper Upper Upper Upper Upper Lower Lower Lower Lower Lower Difference (mm) central incisor lateral incisor canine premolar buccal root premolar palatal root molar mesio-buccal root molar palatal root central incisor lateral incisor canine first premolar first molar mesio-buccal root 0. the unit shows the apex sign.4 0. Common Problem Solving The following are problems frequently encountered by general practitioners when using EALs.4 .4 0. Lee / Dent Clin N Am 48 (2004) 35–54 Fig.1 0 0.4 0.5 0. (A) Initial sign of apex. (B) Sign of apex after canal preparation. Kim. 2. S-J. Removing the metallic restoration or simply blowing air onto the wet chamber usually solves this problem.

34–5. a sudden circuit breaks out. severely bleeding or exudating canal At times. The cause of this phenomenon is too much electrolyte in the canal. Apical limit of root canal instrumentation and obturation. there is little or no electric contact. Lee / Dent Clin N Am 48 (2004) 35–54 51 Sharp drop of the signal at the apical foramen The normal operation of an EAL is demonstrated by the smooth and gentle movement of the signal from the orifice to the apical foramen. which renders a premature reading. Where shall the root filling end? NY State Dent J 1994. open apex When there is an open or blunderbuss-type foramen. . When an EAL is used in dry conditions. the machine reads the largest gradient change in the impedance ratio wherever the file tip meets.E. Premature reading. The total impedance is the sum of the impedance created apically and of the dentin wall. the signal reaches the APEX mark far before the file enters the supposed foramen area. such as for the final working-length verification immediately before the obturation. the impedance change depends mainly on the distance between the file tip and the apical foramen. S-J. When this happens. The canal may need to be blot dried in some cases. A premature reading is probably due to the sharp drop in the gradient of the impedance ratio at the thin dentin wall. Int Endod J 1998. This mostly occurs with a very dry canal. even at higher frequencies. the operator must judge carefully the appropriate position from the sharp dropping. the meter tends to read short from the true apical foramen. gentle irrigation of the canal will reiterate the normal operation of the unit. the signal remains remote from the APEX mark and then drops abruptly as it reaches the apical foramen. As soon as it meets with the apical tissue. which makes it very difficult to locate the apical foramen precisely. As described previously. which brings the signal to the APEX mark. Sometimes. When this occurs. When the file tip is at the extremely dried point. part 1. Because the dentin wall has a much lower electrical capacitance than does the apical foramen. the impedance of the root dentin wall affects the total impedance between the file tip and the lip clip. References [1] Hasselgren G. Apex sign from the beginning. Literature review. the canal should be irrigated gently with sodium hypochlorite or saline until the drainage becomes reasonably controlled. Kim. This phenomenon occurs most often with extreme bleeding and actively draining pus or exudates from the canal. When the dentin wall becomes extremely thin.31:384–93. [2] Ricucci D.

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J Endod 2002. Comparison of radiographic and electronic working lengths. J Endod 2001. Attin T. J Endod 1996. Int Endod J 2001.40(2):200–4. Fulkerson MS. Komorowski RC. [41] Czerw RJ.28(2):83–5. The ability of Root ZX apex locator to reduce the frequency of overestimated radiographic working length.22(4):173–6. Crit Rev Biomed Eng 2000.28(10):706–9.19(4):177–9. [31] Mayeda D. [44] Pilot TF.23(12):719–24. In vitro evaluation of the accuracy of several electronic apex locators. Soares IJ. p. [52] Felippe MC. J Dent Child 1996.27(3):209–11. Shi JN. An in vivo evaluation of an electronic apex locator that uses the ratio method in vital and necrotic canals. [48] Operation instructions Root ZX. Med Biol Eng Comput 2002. Forner-Navarro L. [50] Dunlap CA. J Endod 2002. Lost C.28(3):473–9.28(2):116–9. Kim DW.28(8):595–8. Lee SJ. [46] Nam KC. Walmann JO. The effect of an apex locator on exposure to radiation during endodontic therapy. Barbakow F. Endod Dent Traumatol 1994. Methodological considerations in the determination of working length. [53] Katz A.24(1):48–50. Mass E. Electronic apex locator: a useful tool for root canal treatment in the primary dentition. Lee / Dent Clin N Am 48 (2004) 35–54 53 [29] Wu YN. [30] Lauper R.95(1):94–100. Friedman S. [37] Kaufman AY. [33] Pratten DH.22(5):260–3. MacFarlane TV. Monting JS. [38] Martinez-Lozano MA. J Endod 1993.35(2):186–92. Kim NG. [39] Goldberg F. J Endod 1996.28(7):524–6. [47] Lee SJ.21(11):572–5. In vitro evaluation of an audiometric device in locating the apical foramen of teeth. 4. J Endod 2002. Nam KC.34(5):371–6. Schindler WG. An in vitro evaluation of the accuracy of the Root ZX in the presence of various irrigants. In vivo comparison of gradient and absolute impedance electronic apex locators. Variables affecting electronic root canal measurement. Development of a frequency-dependent-type apex locator with automatic compensation. Kim DW. S-J. Clinical accuracy of a new apex locator with an automatic compensation circuit. De Silvio AC. Weiger R. J Endod 1993. [45] Kim DW. . Int Endod J 2002. [49] Ounsi HF. Flores CM. J Endod 1997. Manfre S. Yoshpe M. McDonald NJ.19(11):545–8. Lutz F. [35] Brunton PA.28(6): 461–3. Walker WA 3rd. Pitts DL. Muller U.25(2):88–92.E. Huang LZ.10(5):220–2. [32] Frank AL. Clinical evaluation of the measuring accuracy of Root ZX in primary teeth. Kim YJ. Int Endod J 1996. [43] Jenkins JA. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003. In vivo measurement accuracy in vital and necrotic canals with the Endex apex locator. Kim SC. Sanchez-Cortes JL. [40] Kielbassa AM. Electronic length measurement using small and large files in enlarged canals. Kim. 2002. In vitro measurement accuracy of an electronic apex locator in teeth with simulated apical root resorption. In vitro evaluation of the reliability of the Root ZX electronic apex locator. Nastri N. Nam KC. J Endod 2002. Kaufman AY. Abdeen D. Naaman A. J Endod 2002. Xu YY. Determination of impedance changes at varying frequencies in relation to root canal file position and irrigant. Donnelly JC. Munz I. [36] El Ayouti A. BeGole EA. Torabinejad M. Influence of the canal contents on the electrical assisted determination of the length of root canals. Steiman HR. Int Endod J 1999. J Endod 1998. Tustin (CA): J Morita Manufacturing Corp. Stamm O. An in vivo evaluation of Endex electronic apex locator. Int Endod J 1992. [42] Meares WA. Kim YJ. The influence of sodium hypochlorite irrigation on the accuracy of the Root ZX electronic apex locator. Lee SJ. [51] Nguyen HQ.29(6):359–64. [34] Pommer O. Kaufman AY. J Endod 1995. Accuracy of a new apex locator: an in vitro study. Llena-Puy C.63(6):415–7. Root canal length measurement in teeth with electrolyte compensation.32(2):120–3. J Endod 2002. Remeikis NA. Keila S. Rauschenberger CR.

30(6):403–7. Reliability of different electronic apex locators to detect root perforations in vitro.19(1):36–44. The accuracy of the Neosono Ultima EZ apex locator using files of different alloys: an in vitro study. Cox CF. Fuss Z. Ludlow MO. In vitro evaluation of the reliability of the Endex Apex Locator. [56] Kaufman AY. . [55] Fuss Z. Kim. Bergenholtz G. Int Endod J 1986. Haddad G. [58] Ibarrola JL. Assooline LS.54 E. J Endod 1999. Chapman BL. Effect of preflaring on Root ZX apex locators. Kaufman AY. Int Endod J 1997. S-J. Periodontal wound healing following intentional root perforations in permanent teeth of Macaca mulatta. Keila S. Determination of location of root perforations by electronic apex locator. Namazikhah MS. [59] Ounsi HF.25(9):625–6. Lee / Dent Clin N Am 48 (2004) 35–54 [54] Beavers RA. Sadeghi K. Howard JH. J Endod 1998. Waxenberg S. J Calif Dent Assoc 2002.24(2):120–1.30(9):681–4.82(3):324–9. Knowles KI. Akha ES. [57] Nekoofar MH. Oral Surg Oral Med Oral Pathol 1996.

root canal treatment causes stress to NiTi files and a stress-induced martensitic transformation takes place from the austenitic to the martensitic E-mail address: Michael.1016/j.de 0011-8532/04/$ . Department of Operative Dentistry and Periodontology.11. being reflected in the term equiatomic. Dr. which follows the naming of the reactions of stainless steel. This alloy is the favorite for use in endodontics (Tables 1.Baumann@medizin. This alloy has been used for some hand files but because of different properties (ie. PhD. and show shape memory and superelasticity [4–6]. lower ‘‘shape memory effect’’ and increased heat treatability. Another type is called 60 NiTiNOL and contains about 5% more nickel (see Tables 1.Dent Clin N Am 48 (2004) 55–67 Nickel–titanium: options and challenges Michael A. Univ. 2). Although temperature changes are used during the manufacturing process.cden. are not heat treatable. have a low modulus of elasticity (about one fourth to one fifth that of stainless steel) but a greater strength. All rights reserved.-Prof. Baumann. The low-temperature phase is called the martensitic or daughter phase (a bodycentered cubic lattice) and the high-temperature phase is called the austenitic or parent phase (hexagonal lattice).uni-koeln. DDS. which is used worldwide for this special type of alloy. nearly the same number of Ni and Ti atoms are combined. This lattice organization can be altered either by temperature or stress. creating the acronym NiTiNOL.see front matter Ó 2004 Elsevier Inc.001 .2003. Maryland. med. The latter two properties are the main reasons why NiTi alloys have succeeded in endodontics and some other dental disciplines and are due to a change in the crystal structure. together with increasing hardness) it seems to be less useful than the 55 NiTiNOL [4]. Using about 55 wt% Ni and 45 wt% Ti and substituting some Ni with less than 2 wt% Co. Germany Nickel–titanium (NiTi) was developed 40 years ago by Buehler et al [1–3] in the Naval Ordnance Laboratory (NOL) in Silver Springs. dent. NiTi alloys overall are softer than stainless steel. D-50931 Ko¨ln. The symbols of the metals were combined with the place of invention. 2) and is commonly referred to as 55 NiTiNOL. University of Cologne. doi:10. Dental School. are tougher and more resilient. Kerpener Strae 32.

No information available. Data from Refs.9 1500–1550 600–610 2000 1600 285103 N/mm2 2 .31 40. it is about 4% [6. the tolerance is about 6% and after 100. Baumann / Dent Clin N Am 48 (2004) 55–67 Table 1 Composition of nickel–titanium rotary and hand files following an EDAX-analysisa Composition File type Machined ProFile (Dentsply Maillefer) Hero 642 (MicroMega) FlexMaster (VDW-Antaeos) Hand NitiFlex K-File (Dentsply Maillefer) UltraFlex K-File (Texceed) Onyx-R-File (Union Broach) Ni Ti Al Fe Co 54. A change in shape occurs.45 6. Wurzelkanalinstrumente fu¨r den manuellen Einsatz: Schneidleistung und Formgebung gekru¨mmter Wurzelkanal abschnitte. This quality is not unique to NiTi because CuZn.26 54.03 0.A. This ability of resisting stress without permanent deformation—going back to the initial lattice form—is called superelasticity. Within this range.000 deformations.56 M.24 a EDAX. together with volume and density changes.36 59.74 0.7].33 0.28 0.32 44.65 45.26 0. The superelasticity is most pronounced at the beginning.05 0. but these alloys are less biocompatible [2. 1998.4]. After 100 deformations. the so-called ‘‘memory effect’’ can be observed: the NiTi file comes back to its original straight form without showing any sign Table 2 Properties of nickel–titanium and stainless steel Property 55 NiTiNOL 60 NiTiNOL cooled from 950 C 6. and NiNb alloys also show it.71 Density (g/cm3) Melting temperature ( C) 1310 1125 Hardness Vickers 303–362 303 Rockwell (30 above (17 below (30 water(60 furnace TTR) TTR) quenched) cooled) Tensile strength (MN/m2) 827–1172 103–862 945 1062 34–138 Near tensile Yield strength (MN/m2) 621–793 strength Modulus of elasticity 83–110 21–69 114 114 (10ÿ3 MN/m2) Elongation % 1–15 ÿ60 7 — Abbreviation: TTR. AuCd.28 45. [4–7]. Data from Scha¨fer E.18 0. CuAl. Stainless steel 7. Energy Dispersive Analysis of X-rays. phase within the speed of sound.97 0 0 16.27 54.40 38.42 0 0 0 0.37 55. —. when a first deformation of as much as 8% strain can be totally overcome.05 0.25 0.28 0. Berlin: Quintessenz.14 43. transformation temperature range.42 45.04 0.

which has a Vickers hardness number of up to 70 [8].A. as shown in the lower right panel. machining and grinding is the only way for NiTi. and root canal dentin. The cutting efficiency of NiTi instruments is not judged uniformly but in the end. however. The Vickers hardness number of NiTi is about 300 to 350. a higher frequency of exchange of files. Machining of the original NiTi wire should be conducted at 220 ft/minÿ1 with carbide burs or silicone carbide wheels (stainless steel tool wear was extremely high) under active highly chlorinated cutting oil involving light feeds and slow speeds [4]. Thus. without any prior notice. the wear increases. it is about one half or two thirds that of stainless steel [11]. see reference [4]). a disadvantage for NiTi hand files is the permanent rotating manner in which modern NiTi files are used in combination with the greater taper: although this increases the cutting ability. 1. is impossible due to the superelastic properties and the memory effect. ProFile (1997) is shown in the upper right panel. Manufacturing In this context. therefore. Nevertheless. the surface of NiTi instruments obviously is not homogenous. In the very beginning. Therefore. which has a value of nearly 30 to 35 [9]. as it is done with stainless steel K files and K reamers. Nevertheless. the manufacturing of NiTiNOL alloys plays a key role for understanding some inherent challenges (for details. This finding meant a lower cutting efficiency and a higher wear than for stainless steel files and. a fracture can occur suddenly. which is about 530. The surface of the early NiTi files was rough with grooves and roll overs. Quantec (1997) is shown in the upper left panel. Both values are far higher than dentin.M. Modern surfaces (RaCe) are much smoother. An experimental file (1998) is shown in the lower left panel. thus leading to Fig. rollover of the edges. which leads some clinicians to maintain that NiTi files are disposable instruments. and Serene et al [10] found that the cutting edges were softer than the core of the instruments. and inhomogeneities often could be observed. milling marks with severe surface alterations. Baumann / Dent Clin N Am 48 (2004) 55–67 57 of lasting deformation. far beneath that of stainless steel. . Twisting.

but the values satisfied International Standards Organization specifications [12]. resilience.. 2). and performed well in a marine environment [2]. The tips of most files are more or less rounded. Older studies tested orthodontic NiTi wires. In addition to inhomogeneities and surface alterations. and finally breakage (Fig. . and changes in load and unload [20]. fatigue. see also Fig. Fig. 5. GT in the upper right. reduced pseudoelasticity. Corrosion and sterilization The environment of the mouth (body temperature. Differences in the effects of sterilization on NiTi alloys also have been fond. LightSpeed is shown in the upper left panel. 1).13].22].58 M. blood) causes corrosion of NiTi alloys [12. Dry heat and steam autoclave decreased the flexibility of stainless steel and NiTi files. meaning corrosion. United States Navy tests found that NiTi had good corrosion resistance. RaCe in the lower left. saliva with its salts and electrolytes. and Hero in the lower right. and surface were unaltered [18]. deflection rate. corrosion and resistance to repeated sterilization are issues that must be discussed. whereas Edie et al [17] saw no difference in surface characteristics under the scanning electron microscope or in terms of oxygen contact. good stress corrosion. More recent studies on endodontic instruments indicate that there are changes but that they are not seen as clinically relevant [12. One study used dry heat.A. Baumann / Dent Clin N Am 48 (2004) 55–67 accelerated wear. Clinical use with sodium hypochlorite (NaOCl) and repeated sterilization ‘‘did not lead to a decrease in the number of rotations to breakage of the files’’ [21]. Some manufacturers have overcome this problem (Fig. These results were confirmed in another study with different files in which sterilization altered the bending moment only slightly [22]. The elastic properties. 2. Corrosion pits in products rich in titanium were described by some authors [14–16]. and a steam autoclave.21. Another group also saw no clinical differences [19]. formaldehyde vapor. whereas other researchers observed a higher stiffness.

In addition. The effect of NaOCl in various concentrations (but without looking at sterilization) was reinvestigated [24]. dentists are asked many questions by their patients. in cases in which a clean stand is filled with a solution of NaOCl for disinfection during root canal treatment. Allergies Nowadays. however. Nickel hinders the mitosis of human fibroblasts [26] but NiTi seems to lack this effect [27] and shows good biocompatibility [28]. At that time. it seems that cavity preparation and endodontics cannot be thought about without the use of modern handpieces and diamond burs. with the special combination of 90 and an up-and-down filing movement. therefore reducing the cutting ability of NiTi files [23]. The first contra angle with a whole circle rotation is attributed to Rollins in 1899—about 1 century ago. One explanation is the equiatomic ratio of Ni and Ti. a relevant time of more than 30 minutes will easily be reached.A. After 30 to 60 minutes. The discovery of NiTi alloys enabled a steadily accelerating development of NiTi files that—first developed and designed for hand instrumentation—enabled a whole range of permanent rotating systems now available in a wide range . Modern ideas in the 1980s were transformed into the canal finder and canal leader. Baumann / Dent Clin N Am 48 (2004) 55–67 59 Another study used spectroscopy to examine the chemical composition of the surface layer and found that repeated heat sterilization altered the superficial structure of the instruments so that the amount of oxygen on the surface was enhanced. ‘‘modern’’ instruments were not developed until the 1930s when Endocursor was designed. San Antonio. and 1964 when Giromatic was developed. One topic that patients ask about is the allergenic potential of endodontic NiTi-files. Since then. are thought to be irrelevant. Texas) instruments. Such contact times are never reached under clinical conditions and. for NaOCl (the main irrigation solution in endodontics). Nickel is the most widespread allergen in the industrial nations because of its usage in fashion jewelry and consumer products [26]. rotating instruments in endodontics and dentistry in general were very rare. Nevertheless. therefore. statistically significant amounts of titanium were dissolved from the tested LightSpeed (LightSpeed Endodontics. 1958 when Racer was introduced. sonic and ultrasound devices appeared but never really succeeded. there is a hint of pitting corrosion after sterilization and exposure to 5% NaOCl [13]. A recent study showed that ‘‘repeated sterilization under autoclave or exposure to sodium hypochlorite (NaOCl) before sterilization did not alter the cutting efficiency of PVD (physical vapor deposition)-coated NiTi K-files’’ [25].M. Chronology of nickel–titanium use in endodontics When the Gates–Glidden (GG) bur was invented in 1885.

and the H file. The combination of the old idea of 360 rotation with the new technology met with great success. and the market: LightSpeed. ProFile. and Quantec. instruments for manual preparation of the root canal system have been manufactured in a similar way: there are three main types. Various NiTi systems are described throughout this issue and many studies have been designed to evaluate the advantages and disadvantages of them. and theory has enabled fast development and improvements that are reviewed here. A second generation of NiTi instruments. International standards organization recommendations For almost a hundred years. the K file.A. Baumann / Dent Clin N Am 48 (2004) 55–67 Table 3 Chronology and selected data of rotary Nickel–titanium files Instrument Year Cross-section Taper Tip NT Engine LightSpeed Mity roto ProFile Orifice Shaper PowerR Quantec GT rotary Hero 642 RaCE FlexMaster ProTaper K3 Endostar NiTi-Tee K2 MFile 1991 1992 1993 1993 1993 1994 1996 1998 1999 1999 2000 2001 2001 2001 2002 2002 2003 Modified U file U file U file U file U file Modified U file Modified Modified Modified Modified Modified Modified Modified Modified Modified 02 00 02 02–06 05–08 02–06 02–12 04/06–12 02–06 02–10 02–06 Multiple/reverse 02–10 02–10 02–12 02–08 02–06 Pilot Pilot Pilot Pilot Pilot Pilot Various Pilot Modified active Pilot Modified active Modified active Pilot Pilot Pilot Pilot Pilot H file K file H file K file K file K file K file K file S file Uni file K file of types and brands. even after 15 years. three brands have dominated the discussion. The sequence of NiTi files opened with NT engine files by McSpadden and the LightSpeed system by Wildey and Senia [29] and finds its preliminary end today with the MFile by Brasseler (Table 3). the ideas. however. which all share features that are common and widespread in nearly all systems. namely the reamer.60 M. During the last several years. research. Over the years. The common feature of all three is that they have a total cutting length of 16 mm and an . A large number of articles can be found when looking on the Internet for NiTi (424) or NiTi and dentistry (221). there have been some changes in the fundamental design. and progress continues to be made. A complete book on root canal treatment with Ni-Ti instruments has been edited by Quintessence in Germany in 2002 [30] and many scientists and practitioners around the globe focus on this new mechanical approach to shape the root canal.

6) [31]. Exceptions are the early Quantec design.57 mm). 0. Cutting egdes In the beginning. .02 mm per millimeter. 4). and 13. Quantec LX. System GT (see Fig. Varying the flute height: examples are GT rotary files and System GT (see Figs.33 mm in GT 0. 5) in which the cutting edges go far to the tip.5 mm. an instrument designated as size 25 is 25/100 mm thick at the tip (ie. cutting edges had been flattened. System GT).12.32 mm thicker (ie. RaCe finally shows alternating of short twisted with straight areas (see Figs. Baumann / Dent Clin N Am 48 (2004) 55–67 61 increase in diameter by 0. 8 mm in GT 0. At the end of the cutting edge. This technique was the standard until the NiTi era began. To overcome this problem. Common features of nickel–titanium files Tip The tip is mostly rounded to serve as a guide within the canal without cutting at all (Fig. Shortening the cutting edges: System GT with d0 = 0. with some sharp edges at the end (Fig. 10 mm in GT 0. it is 16  0. ProFile. and FlexMaster (Fig. the early ProFile. although because of the significantly higher risk of screwing themselves into the canal. Modifiying the edges: Quantec (see Fig. The cutting edges meet the canal wall at different angles (reamer with an angle of approximately 20 . LightSpeed. 6). 3). or shorten the cutting edges and vary the flute height or taper. 6) or the MFile (see Fig. which had a sharp cutting tip with 60 or 90 (Fig.5 to 1. This increase in diameter is termed a taper of 2%.20 mm (6. K files with 40 .25 mm + 0. GT rotary. 2. 0. and H-files with 60 ). 5. 3) and K3 have very complex cutting edges that stay between the flattened and sharp edges and are thought to enhance the cutting ability and combine a big chip space with a strong core.02 mm = 0. 1).06). ProFile.A. In addition.66 mm in GT 0.10. and the ultimate reduction of LightSpeed with 0.32 mm = 0. reamers have only around half as many cutting edges as K files. MFile with 4 to 6. Orifice Shapers. System GT). K files are considerably more effective than K reamers.75 mm (Fig. This flattening was necessary because every permanent rotating system has the tendency to screw into the canal. eg.25 mm). named ‘‘radial land’’ (ie.08.M. they must not be turned in the canal more than half a circle (180 ). 4. In addition. 4. clinicians could flatten. For example. for LightSpeed. modify. the cutting edges are always positioned at equal intervals so that all endodontic instruments of this type are basically designed to be similar to a screw. making a reaming motion possible with only a slight tendency for the reamer to screw itself into the canal. All of these ideas have been used in one or another systems: Flattening the edges (radial lands): used in LightSpeed. see also Fig. RaCe files with 9 or 10 mm. 6).

Many NiTi file brands show flattened cutting edges like LightSpeed (upper left). Mity roto) or created a no-taper variance (LightSpeed). ProFile (lower left).A. Baumann / Dent Clin N Am 48 (2004) 55–67 Fig. Orifice Shapers. The first systems stayed in this tradition (NT Engine. triple. and ProTaper also have ‘‘odd’’ taper. Varying the taper: one of the very new ideas of NiTi file development is the increase of the standardized taper. The Quantec tip has gone through a special development: from a 60 degree tip (upper left) and a 90 degree variation (upper right) to a shield tip (lower left) and a torpedo tip (lower right). and so on.06mm.06 means that with every millimeter of cutting length. Quantec SC with a complex cutting surface (upper right). lower right). . 3. producing parallel walls for the first time. having reverse and multiple taper within one file [32. center).33]. There are not only ‘‘even’’ taper but some systems like Quantec. The ProTaper system (see Fig.04 means that with every millimeter of cutting length. MFile (notice the change of flute heights.04 mm. A triple taper or taper . A double taper or taper 0. which was 2% normally referring to the International Standards Organization standard (see Table 3). Starting with ProFile. and GT rotary (change of flute heights. the instrument gets bigger by 0. Fig. the instrument gets bigger by 0. and higher (‘‘greater’’) taper pioneered its way. the double.62 M. 4. 5) defies imagination.

Flexmaster. MFile in the upper right. some aspects of contemporary file designs have been addressed. LightSpeed in the lower left. used up to total length with size 25 0. By having better ways of manufacturing and grinding NiTi wires and calculating mathematic models of stress [34]. Hero 642). 5. To replace the old-fashioned but effective GG-burs.A. 6. is a size 25 0. The Orifice Shapers from Dentsply Maillefer are six instruments with high taper (5%–8%) and a short working end. some manufacturers began to produce sharp cutting edges (eg. many manufacturers designed similar NiTi instruments. ProTaper in the lower left. ProTaper) [32. This sharp cutting edge results from a triangular cross-section (eg.M. The IntroFile from VDW-Antaeos Fig. ProTaper shows a variation of taper and a change from flute height. and RaCe in the lower right. a change to sharp cutting edges has been undertaken and some brands show this variability. being only 19 mm from tip to handle and exactly the same as file 8. . and RaCe in the lower right. RaCe exhibits an alternation of twisted and straight areas. A shortening of cutting edges is one way to decrease the tendency of NiTi files to screw into the root dentin. but being 25 mm length. FlexMaster is shown in the upper left panel. GT rotary files are shown in the upper left panel. ProTaper. Hero in the upper right.06. File 1 from Quantec. Recently.06. used for crown down. Baumann / Dent Clin N Am 48 (2004) 55–67 63 Fig. New approaches and challenges When referring to reverse and multiple taper.35]. FlexMaster.

the possibilities of coating the surface is discussed in the literature [25. A highly interesting monograph dealing with this subject in extenso is the book Endodontic Instrumentation: Essentials for Expertise by McSpadden [36]. whereas the ionic implantation and thermal nitridation showed no loss in cutting ability over 240 seconds. Another way to overcome this problem has been developed by FKG. Fatigue.0  1017 per ion/cm2. Finally. which will be published soon.64 M. scanning electron microscope studies for testing the cleaning and shaping ability. There are some leading scientists and companies that are driving the development of NiTi technology. clinical trials. resulting in a poor surface texture with roll overs and grooves.10 taper/size 40). The SET identity—a special box that calculates the cycles and life span of NiTi files—may provide an answer (see Fig. with size 50 thus needing a comfortable size of the canal entrance. the NiTi alloy is a strange alloy that barely can be machined. apex locators in combination with high-tech endodontic motors. 5). As previously discussed. the enhancement of cutting ability and file design using plastic block studies. the manufacturer of RaCe files. Another approach is the thermal nitridation for 480 minutes at 500 C or ionic implantation with 150 keV nitrogen ions at doses of 1. and many others (for review. Therefore. Regular ProFiles showed a decrease in cutting ability after 80 seconds. is an unsolved problem and another challenge for NiTi manufacturers. which cannot be expected anyway. Lee et al [37] found that the implantation of 4. The obvious advantage of all these approaches is that the tip diameters are mostly smaller than the smallest GG-bur.37–41]. One approach is ionic implant and thermal nitridation [42]. Summary A large number of studies have dealt with various aspects of NiTi files. This discussion reflects some of the aspects that have arisen with the variation of NiTi file designs.8  1017 per ion/cm2 of boron increased the surface hardness. The higher flexibility of NiTi is another point. such as the physical and chemical characteristics of NiTi alloys and the original files available. the biologic acceptance and allergies. special motors. Baumann / Dent Clin N Am 48 (2004) 55–67 (Mu¨nchen–D) has taper 11% and a tip diameter size 22. and others . a physical vapor deposition of TiN also increased the cutting ability [43] and helped the files to withstand repeated sterilization or exposure to NaOCl [25]. Side developments of endodontics such as different irrigations and lubricants. FKG offers stainless steel files for crown down (0. student studies. see reference [30]). The GT rotary files and System GT also can serve as crown down instruments. new filling methods. the question of torque and fatigue.08 taper/size 35 and 0. A last aspect under discussion is the enhancement of the surface hardness of NiTi files. This discussion has been closely related to the invention of specific endodontic motors with torque control. The wear resistance of ProFiles was enhanced with both approaches.A. however.

’’ Of course. Ein Handbuch. circumferential filing is not possible or only restrictedly possible with NiTi files.M. Wurzelkanalaufbereitung mit NickelTitan-Instrumenten. [5] Civjan S. there is evidence that NiTi files lead to a more centered canal form that is very close to the original but have a tendency of straightening the canal when the instrument is left too long within the canal. the large studies in Glasgow on plastic blocks by Dummer and colleagues [4] and in Go¨ttingen on extracted teeth (see review in [30]). [2] Buehler WJ. blockages. Cross WB. and canals are not really round all over. looking for straightening. 2002. A summary of recent research on the Nitinol alloys and their potential application in ocean engineering. Of course. or any NiTi rotary system.34:1475–7. Wiley RC. 35–46. J Dent Res 1975.1:105–20. every success with dental performances mainly depends on the dentist and secondly comes from the material.2:41–9. loss of working length. Metallurgie und Eigenschaften von Nickel-Titan-Instrumenten zur maschinellen Wurzelkanalaufbereitung. Potential application of certain nickel-titanium (Nitinol) alloys. In: Hu¨lsmann M. Wire J 1969. Ocean Eng 1968. In this context. NiTi hand files. 33:297–310. a complete instrumentation and herewith cleaning of canal walls cannot be achieved by mechanical means. [6] Scha¨fer E. claiming the ever heard warnings that there is nothing better than the ‘‘good old times’’ and a highly advanced filing technique by hand. ‘‘independent from the study design or observer. Huget EF. permanent rotating instruments only can create round holes. The combination of the use of contemporary available modern devices and files with a solid base of anatomic and biologic knowledge will lead to a predictable higher quality of root canal treatment on a broader basis.A. DeSimon LB. thus helping to preserve more teeth for more years in the mouth. Berlin: Quintessenz. Of course. Baumann / Dent Clin N Am 48 (2004) 55–67 65 have caught the ‘‘wave of technisation. p. neither with stainless steel hand files. References [1] Buehler WH. Of course. Int Endod J 2000. J Appl Phys 1963. An overview of nickel-titanium alloys used in dentistry. . endodontics is a mirror of the world: some dentists and scientists defend their old bastions and argue to stay with hand instrumentation. Effect of low temeperature phase changes on the mechanical properties of alloys near composition TiNi. [4] Thompson SA. and are ‘‘riding the wave.45]. and perforations found that there are differences between brands and that some do not proceed as well as others but overall. others have thrown away all their old instruments and former ways of proceeding. editor. Of course.54(1):89–96. Gilfrich JV. Wang FE. Hannover and Ko¨ln) have changed their endodontic concept by totally changing from hand instrumentation to NiTi files with endomotors for the past 3 years. fractures. with great success [44. the results for the most systems differed only slightly and were highly constant’’ [30]. Some universities in Germany (ie. 55-Nitinol unique wire alloy with memory.’’ In this way. [3] Buehler WJ. working time.

Tripi TR. Louis (MO): Ishiyaku Euro-America. Effect of the sterilization on the cutting efficiency of rotary-nickel-titanium endodontic files. J Dent Res 1958. The microhardness of enamle and dentin. Zaytoun MP. Cyclic fatigue of ProFile rotary instruments after clinical use. Eur Surg Res 1992. 2002. Briatico-Vangosa G. Effects of sterilization on the mechanical propeties and the surface topography of nickel-titanium arch wires. Application in endodontics. 1993. Are endodontically treated teeth more brittle? J Endod 1992. Bontinck WJ. 1998. Haugen JW. Kuftinec MM. [11] Scha¨fer E.88:343–7. St.66 M.28:15–25. Surface corrosion of Nitinol and stainless steel under clinical conditions. Biomaterials 1999. The corrosion susceptibility of modern orthodontic spring wires [abstract]. Abstract 1035. A new root canal instrument and instrumentation technique: a preliminary report. Berlin: Quintessenz. Int Endod J 2002. Casey GR. Senia S.102:120–6.37:661–8. [28] Ryhanen J. Berlin: Quintessenz. J Endod 1999. Kaestner W. [14] Sarkar NK.51:319–24.18: 332–5. [12] Canaldi-Sahli C. Kusy RP. Ein Handbuch. Accessed on January 22. Messer HH.31:48–52. Bonaccorso A. 2004. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999.102:153–9. Willershausen B. Sentis-Vilalta J. [26] Basketter DA.60A:628. Available at: http:// www. [13] Aten JC. [30] Hu¨lsmann M.25:288. Vicentini B. Effect of sterilization on the cutting efficiency of PVD-coated nickel-titanium endodontic instruments. Kaulesar SuKul GM. Sener B. Oulu. cobalt and chromium in consumer products: a role in allergic contact dermatitis? Contact Dermatitis 1993.67:198. J Dent Res 1980. [15] Clinard K. Effects of sodium-hypochlorite on nickel-titanium LightSpeed instruments. Inc. Abstract 1277.sma. [25] Scha¨fer E. Peyton FA. 1999. Am J Orthod Dentofac Orthop 1988.33:204–7. [24] Busslinger A. The effect of clinical use and sterilization on selected orthodontic arch wires.A. Am J Orthod Dentofac Orthop 1992. Watanabe LG.35:867–72. Oral Surg Oral Med Oral Pathol 1989.24:378–82.html. [21] Yared GM. Bijma A. Load-deflection characteristics of nickel-titanium alloy wires after clinical recycling and dry heat sterilization. Chicago: Northwestern University of Chicago. Wurzelkanalaufbereitung mit Nickel-Titan-Instrumenten. PA: Johnson Matthey. Finland: University of Oulu. Am J Orthod Dentofac Orthop 1992. 1995. Wurzelkanalinstrumente fu¨r den manuellen Einsatz. Saxena A. Int Endod J 1998. Bou dagher FE. Schneidleistung und Formgebung gekru¨mmter Wurzelkanalabschnitte. von Fraunhofer JA. [16] Rondelli G.20:785–92. Lally C. Biocompatibility evaluation of nickel-titanium shape memory alloy [dissertation].59A:528. [23] Rapisarda E. Baumann / Dent Clin N Am 48 (2004) 55–67 [7] NiTi Smart Sheet. [27] Putters JL. [8] Sedgley CM. [22] Briseno Marroquin B. Influence of different sterilisation procedures on the bending moment of stainless steel and nickel titanium root canal instruments [abstract]. von Fraunhofer JA. [20] Kapila S.93:232–6. Angle Orthod 1981.31:290–4. [10] Serene TP. The simulation of clinical corrosion of endodontic files [master’s thesis]. Besselink PA. Condorelli GG. Int Endod J 1998.-inc. . Nickel-titanium instruments. nickel and titanium: a biocompatibility estimation. Abstract OR23. Barbakow F. The effect of sterilization on bending and torsional properties of K-files manufactured with different metallic alloys. Andreasen GF. Comparative cell culture effects of shape memory metal (nitinol). [9] Craig RG. [18] Mayhew MJ. J Dent Res 1981. [29] Wildey WL. Machtou P. Schwaninger B. [17] Edie JW. Int Endod J 2000. Localized corrsion behaviour in simulated human body fluids of commercial Ni-Ti-orthodontic wires.com/html/selected_properties. de Zeeuw GR. Adams JD. [19] Smith GA. Nickel. West Chester. The in vivo corrosion of Nitinol wire [abstract]. Brau-Aguade´ E.

[34] Turpin YL. Wurzelkanalaufbereitung mit Nickel-Titan-Instrumenten. [38] Rapisarda E. [44] Baumann MA. Dental Clin N Am 2004. [32] Baumann MA. Cathelineau G. Tripi TR. Chagneau F. Effect of endodontic skill on root canal preparation with ProFile. Serene TP. Effect of physical vapor deposition (PVD) on cutting efficiency of nickeltitanium files. 129–38. Marino R. ProTaper—eine neue Generation von NiTi-Feilen. Endodontie 2001. [40] Tripi TR.M.10(4): 351–64.6(2):13–20. Condorelli GG. [37] Lee DH.27:588–92. Working with the FlexMaster system. editor. Ein Handbuch.22:543–6. Biomed Mater Eng 1996. p.2:28–31. Condorelli GG. Bonaccorso A. Park B. The effects of surface treatments of nickel-titanium files on wear and cutting efficiency. Impact of torsional and bending inertia on root canal instruments. Bonaccorso A. J Endod 2001. Saxena A.28:800–2.89:363–8. et al. Torrisi L. Root canal shaping with manual stainless steel files and rotary NiTi files performed by students. Condorelli GG. Fragalk I. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999. [43] Scha¨fer E. [45] Sonntag D. Bonaccorso A.36: 246–55. Ion implantation and thermal nitridation of biocompatible titanium. Enhanced surface hardness by boron implantation in nitinol alloys.88:714–8. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000. J Endod 2002. [35] Baumann MA. Depositions of nitrogen on NiTi instruments.6:379–88. Condorelli GG. J Endod 2001. J Endod 2003. Vulcain JM. 2002. Stachniss V.28:497–500. Bonaccorso A. Baumann MA. [42] Torrisi L. Tripi V. J Endod 2002. Tripi TR. [33] Clauder T. Rapisarda E. J Endod 1996. Roth A.27:333–6. Ramifications of design considerations. In: Hu¨lsmann M. [41] Tripi TR. RaCe-System. Kim SK. Guntermann A. [36] McSpadden J. Endod Prac 2003. ProTaper. . Fragalk I.A. Berlin: Quintessenz.29:132–4. [39] Rapisarda E. Endodontie J 2003. Fabrication of hard coatings on NiTi instruments. Inte Endod J 2003. Wear of nickel-titanium endodontic instruments evaluated by scanning electron microscopy: effect of ion implantation. Bartier O. Baumann / Dent Clin N Am 48 (2004) 55–67 67 [31] Baumann MA.04.

06 taper instruments were developed for those clinicians who preferred a fuller canal preparation than could be obtained using a 0. School of Dental Medicine. 0. The NiTi files have the unique properties of superelasticity and shape memory [1]. 0.Dent Clin N Am 48 (2004) 69–85 The ProFile system Yeung-Yi Hsu. MS1. MD(hon)b a Private Practice. Oklahoma) were the one of the first NiTi instruments on the market. USA * Corresponding author. PhD. DDS. The superelasticity of NiTi allows deformation of as much as 8% strain to be fully recoverable. In 1994. NiTi hand files and rotary instruments have become popularized because of their superiority in managing curved canals. and Orifice Shapers. When the stress decreases or stops. Philadelphia. No. The Orifice Shapers system comprised six instruments with a shorter working blade and larger taper. Further developments included increasing taper.04 taper instruments were initially designed for the carrier-based obturation technique.04 taper.*. in comparison with a strain of less than 1% for stainless steel. Road. School of Dental Medicine. The manufacturer soon developed rotary counterparts due to the canalcentering capacity and less aggressive cutting of NiTi.12 taper and were designed to cut more coronal dentin while the instrument tip passively followed the canal without 1 Formerly of the Department of Endodontics. 9.04 taper. The ProFile instruments made by Tulsa Dental (Tulsa.2003.006 .2]. University of Pennsylvania.06 taper rotary instruments. 7 Shihlin District. Dr. These instruments were designed to provide continuous shape in the coronal parts of root canals.a.tw 0011-8532/04/$ .02 taper was marketed. the first product of the Pro Series 29 (Tulsa Dental) stainless steel and NiTi hand instruments with a 0. doi:10. In 1996.cden. University of Pennsylvania.06. Lane 81. E-mail address: yyhsutw@yahoo. Taiwan b Department of Endodontics.11. PA 19104-6030. DDS.com. 0. GT files had 0. The 0. Taipei 111. Sec. PA. 11F.1016/j. All rights reserved.see front matter Ó 2004 Elsevier Inc. Stephen Buchanan proposed a series of even larger taper hand files named Greater Taper (GT) files. including ProFile Series 29 0. Syngcuk Kim. Chung-shan N. 240 South 40th Street.10. USA Since the introduction of nickel–titanium (NiTi) to endodontics in 1988. NiTi alloy will spring back to its original shape without permanent deformation [1. The 0.08. and 0. MPhil.

The noncutting tip and symmetric radial lands design allow the file to remain self-centered as it rotates through 360 . Kim / Dent Clin N Am 48 (2004) 69–85 engaging the wall [3].-Y. GT rotary instruments and ProFile 0. The taper of the instrument affects the increase in diameter along its length. It is claimed that fewer instruments are required to enlarge to master apical file size. Thus.04 and 0. Series 29 The rate of increase between file sizes in this series is at a constant of 29%. which may create difficulties and complications while shaping curved canals [3]. After the merge of the Tulsa Dental and Dentsply companies in 1998. which possess a tapered central core. The radial lands also add peripheral mass that contributes significantly to the strength of the instrument. D16.70 Y. S.06 taper with International Standards Organization (ISO)-sized tips were marketed.7]. Unique file design Cross-sectional geometry The ProFile instrument family. Irvine. all have the same cross-sectional geometry.04 taper and 0. The ProFile system with increased tapers has been developed in the hope that the greater flare along the instrument shaft would automatically create the divergence required for obturation. Hsu. In contrast to a 50% size increase between ISO size 10 and size 15 and a 33% increase between size 15 and size 20. Today. Every ProFile file has a bullet-nosed tip with a rounded transition angle. however. California) [4] and ProTaper (Dentsply International. There is a central parallel core inside that may account for the enhanced flexibility compared with Quantec (Tycom. Orifice Shapers.02 mm per millimeter from the tip (D0).06 taper. This noncutting tip will follow a pilot hole and guide the instrument into the canal. These configurations prevent the instrument from ‘‘screwing into’’ the canal while rotating. is 0. the 29% increment has the advantage of smooth transition among the smaller sizes.32 mm wider than D0. the ProFile system is one of the best-selling rotary instrument systems in the world. including Profile 0. The ProFile ISO-sized tip system was more popular in Asia and Europe. There is a much greater leap of size increment in larger files. In a standard 0. It has a 20 negative rake angle at the cutting edge and flat radial lands to cut dentin in a planing motion. the diameter increases by 0. The following section thoroughly reviews this system. . Table 1 shows the size equivalents of Series 29 instruments compared with ISO sizing.02 taper file. Pennsylvania) [5]. The shape is made by machining three equally spaced U-shaped grooves around the shaft of a taper NiTi wire. theoretically decreasing the potential for canal transportation and procedural errors to occur [6. The U-shaped grooves provide the space to accommodate dentin shavings while planing of the canal wall. which is the file diameter 16 mm away from D0. The 20 helical angle was designed to remove the shaving debris coronally while the instrument rotates clockwise. and GT files. York.

semiactive.64 mm wider than D0. thus.360 0.279 0.129 0. different degrees of taper account for different lengths of blade. deformation on contact with simulated canal/tooth substance is induced. shaping ability. Dr.’’ Machining efficiency has been shown to relate to the alloy used and to cross-sectional geometry [10].216 0. and effect of NaOCl and sterilization. Kazemi et al [13] demonstrated that NiTi files are comparable with or better than stainless steel files in terms of machining dentin.600 0.-Y. RaCe File [FKG . As such. This reduction in efficiency may be explained by the fact that NiTi has a very low modulus of elasticity and.7.8].000 For a 0. the clinical performance of the ProFile system is divided into the following sections: cutting/machining efficiency. Clinical performance The clinical performance of the ProFile system in general is rated good and is comparable to other NiTi rotary systems [4. Besancan. Cutting/machining efficiency Machining efficiency has been defined as ‘‘the procedure of removal of simulated canal/tooth substance with the fluted material.12] found that the NiTi files cut less efficiently than stainless steel files. Johnson [14] classified all rotary instruments as having active. cleaning efficacy. Kim / Dent Clin N Am 48 (2004) 69–85 71 Table 1 Size equivalents of ProFile Series 29 and standard ISO sizing ProFile Series 29 size ISO equivalent size (mm) 2 3 4 5 6 7 8 9 10 0.’’ Haı¨kel and other investigators [11.06 taper instrument. The divergent results may be due to the different behavior of files when cutting Plexiglass and dentin substrate.775 1.9]. France]. or passive cutting blades. ProTaper [15]. HERO 642 [Micro-Mega. For a more detailed discussion. S. Haı¨kel and colleagues [11] defined cutting efficiency as the ‘‘mass of Plexiglass cut per unit of energy used by the test file. D16 is 0.20 mm and a fixed maximal flute diameter of 1.96 mm wider than D0 [3. D16 is 0. Hsu.Y. The GT file has a fixed D0 diameter of 0.167 0.04 taper instrument.0 mm. The ProFile system fits into the category of passive instruments. and for a 0. The slight negative rake angle and radial lands make the files cut less aggressively than those having active cutting blades (eg.465 0.

and transportations could be seen on the impressions. Hsu. Intracanal impressions of prepared canal demonstrated that most canals had definitive apical stops. even less instrumentation time is required compared with the LightSpeed (LightSpeed Inc. requires an appropriate apical size (ProFile Series 29 size 5 and above) to become effective in bacterial reduction [29. Completion of NiTi instrumentation yielded 28% negative culture samples [27].25% sodium hypochlorite (NaOCl) as an irrigant further increased the percentage of negative culture to 61.9. The ultimate goal of endodontic treatment is to prevent or eliminate infection within the root canal system [24].23]. Because fewer instruments are used in the ProFile system.72 Y. elbows. Texas) and Quantec systems [18. There was a substantial bacterial reduction with progressive filing to larger sized files.-Y. Shaping ability Several studies have confirmed the ability of rotary NiTi files to stay centered [17. and good flows and tapers. The instrumentation time required for NiTi rotary instruments is generally less than for stainless steel hand files [8. Switzerland].16]). Therefore. Several canal aberrations such as zips. not only the ProFile system but also all NiTi instruments must be used with caution when larger sizes and greater taper files encounter severely curved canals. The result was comparable to Ørstavik et al’s [28] study in which no detectable bacterial growth in 43% of teeth immediately after extensive apical reaming with saline irrigation was found. None of the canals became blocked with debris in either system. NiTi instruments still tended to straighten within the canals. York. NaOCl.7.9%.18] and to maintain canal curvature better than stainless steel hand files [19–21].22] presented a series of studies on the shaping ability of ProFile 0. Cleaning efficiency Numerous studies in the literature have established the role of bacteria and their by-products in the pathogenesis of apical periodontitis.30]. This indicates that NaOCl . San Antonia. Pennsylvania]) and those having semiactive cutting blades (eg. Similar phenomena were also found in extracted human teeth [4]..19–21]. The loss of working length averaged 0. S. Quantec [14. Kim / Dent Clin N Am 48 (2004) 69–85 Dentaire. Thompson and colleagues [6.04 taper Series 29 and ISO-sized tip using simulated root canals of different curvatures and shapes. Despite their superelastic property. smooth canal walls.5 mm or less. Pow-R [Moyco Union Broach. Less instrumentation time could further reduce operator and patient fatigue. Dalton et al [27] demonstrated that the amount of bacterial reduction after ProFile rotary instrumentation was comparable to stainless steel hand files when saline was used as an irrigant. Classic series of studies regarding antibacteriologic effects of the individual steps in endodontic procedure were performed by Bystro¨m and Sundqvist [24–26] using stainless steel hand files. Adding 1. however.

According to the results of their studies. This finding proved the necessity of using chemical irrigant to dissolve tissue debris and smear layer while undergoing canal preparation with rotary instruments. especially in oval canals such as mandibular incisors and distal roots of mandibular molars [23. GT rotary. Mechanical instrumentation with NaOCl irrigation. Canal shaping with ProFile and other NiTi instruments usually results in a round preparation and smear layer formation [18]. S. Sterilization had been suggested as a way to rejuvenate NiTi files by reversing the stress-induced martensite transformation to the austenite phase [35].34] also demonstrated that when ProFile rotary instruments were used on extracted teeth. Silvaggio and Hicks [36] also proved that sterilization of ProFile 0. irrigation with 2.-Y. Safety concerns Although NiTi rotary instruments have the advantages of superelasticity.04 taper. Effect of NaOCl and sterilization on ProFile Corrosion was the major concern regarding NaOCl irrigation while using NiTi instruments. Hsu. Therefore. steam autoclave. The cutting efficiency also was not affected by the presence of NaOCl. the cleaning efficacy of NiTi rotary instruments was questioned.31]. Yared et al [33.Y.34] demonstrated that sterilization by dry heat or steam autoclave did not shorten the lifespan of ProFile 0. They demonstrated that approximately 35% to 40% of the canal surface remained untouched after complete instrumentation. Kim / Dent Clin N Am 48 (2004) 69–85 73 irrigation is an important step in the reduction of canal bacteria during rotary instrumentation. Haı¨kel et al [11.32] showed that after 2. their use does have .04 taper files in dry heat. Chloride corrosion can leave micropitting on instrument surfaces and lead to areas of stress concentration and crack formation. Yared et al [33. however. the ProFile 0.5% NaOCl did not lead to a decrease in the number of rotations to breakage of the files.06 taper ISOsized tip files could be safely used up to 10 times in vitro or for four molars in vivo.06 taper ISO-sized tip files. and ProFile 0. and good efficiency with less fatigue. shape memory. The debris score and smear layer score after ProFile instrumentation were reported to be significantly lower in the 2.5% of canals void of bacteria [30]. intracanal medication with calcium hydroxide for at least 1 week is recommended. NiTi K file. In the presence of apical periodontitis.5% NaOCl treatment for 12 and 48 hours.5% NaOCl/17% EDTA group than in the tap water group [31]. namely. Peters and colleagues [31] used micro-CT to access canal geometry after preparation with four different techniques. cannot constantly render canals bacteria-free. One-week calcium hydroxide medicament could render 91. Lightspeed. or satim autoclave sterilizer up to 10 times does not increase the likelihood of fracture. there was no significant change in the mechanical properties of ProFile instruments.

0. Problems with debris extrusion using the ProFile rotary system were investigated by Hinrichs et al [40] and Reddy and Hicks [41]. S. Even with the design of radial lands. and instrument deformation and failure.74 Y. Therefore. visual examination is not a reliable method for evaluation of used NiTi instruments [42]. Therefore. The clinician must recognize the risk factors to prevent separation from occurring. Torsional fracture occurs when the . Extrusion of debris When endodontic therapy is performed. They demonstrated that the amount of debris extruded with ProFile files was comparable to the balanced-force technique using flex-R files but was significantly less than the step back technique using hand K files. larger sized ProFile instruments with greater taper such as the ISO size 35. After the length is obtained. and to the reaming motion of the ProFile rotary system and the balanced-force technique that extrudes less debris than the ‘‘push-pull’’motion of manual stepback technique.-Y. but should try to withdraw the file while still rotating or reverse the direction of rotation to drive the file out of the canal. particularly regarding the direction of the curvature and location of apical terminus.06 taper file still tends to ‘‘thread into’’ the canal [37]. torsional and flexural fractures. namely. There are two modes of failure that cause rotary instrument separation. length determination before use of rotary instruments is essential. there appears to be a difference in tactile awareness. The amount of debris extrusion was positively related to the amount of irrigant extruded but irrelevant to canal length. Instrument deformation and failure Intracanal instrument separation is the most frustrating mishap that occurs when operating the NiTi rotary system. extrusion of debris. the clinician should keep this length while operating the rotary instruments. Loss of tactile sensation When using rotary instruments compared to hand files. then the clinician should not stop the instrument rotating. Breakage of NiTi instruments can occur without any visible sign of unwinding or permanent deformation. If the file threads in. and foramen size [40]. Hsu. There is less feedback from rotary instruments. in part. to the flute design of ProFile instruments that aids in debris removal. mechanical and chemical irritants may be inadvertently introduced into periradicular tissue and cause postinstrumentation flare-ups. The lesser amount of debris extruded may be due. Preflaring the canal orifice facilitates more accurate and consistent reading of working length [38.39]. curvature. Kim / Dent Clin N Am 48 (2004) 69–85 safety concerns including loss of tactile sensation. Properly angulated radiographs and an electronic apex locator are necessary.

When using instruments of greater taper. With every 180 of rotation. the most appropriate choice would be a 0. Cyclic fatigue is synonymous with metal fatigue. the torque increases as a consequence of the increased contact area between the file and dentinal wall. The radius of curvature is likely the primary reason for instrument separation due to cyclic fatigue. when the file advances further into the canal. Hsu. the clinician should select an instrument with high strength to prevent torsional fracture.02 taper yet is less susceptible to cyclic fatigue than a 0. then problems with torsional fracture and cyclic fatigue need to be considered.-Y.45]. it is compressed on the inner side of the curve and stretched on the outer side of the curve. Therefore. Radius of canal curvature is the most important factor in determining the torque value. resulting in cyclic fatigue and. fractures [14].02 taper file for its least susceptibility to metal fatigue. it binds against tooth structure. the first thing to cut is the coronal portion of the canal. The amount of torque generated while rotating in the canal is positively related to the mass of the instrument. A smaller radius with an abrupt curve induces greater fatigue than a lager radius with a sweeping curve [14]. The ideal amount of pressure to be used for rotary instruments is the equivalent of the pressure applied when using a sharpened pencil without breaking the lead [14]. As an instrument rotates in the canal. should be selected [14].06 taper rather than 0. which places friction on the instrument called torque. If the curvature is somewhat in between the two aforementioned conditions. Therefore. S.44]. Larger sized and greater taper files. Avoidance of torque failure requires maintaining adequate lubrication during instrumentation [14]. the pressure should be lessened to prevent torque from building up [14].04 or 0. As the instrument goes deeper into the canal. Kim / Dent Clin N Am 48 (2004) 69–85 75 torque limit of the instrument is exceeded. cyclic fatigue will occur more quickly. Consequently.02 taper will provide more torque resistance. To prevent intracanal breakage of instruments. which has more torque strength than 0. The larger sized or greater taper file sustains more compressive and tensile forces due to increased metal mass. will create more torque value on contact with the canal wall [14. Therefore. the instrument flexes and stretches over and over again. gaining straight line access (coronal and radicular) is the first step in obtaining an uninhibited path for the .Y. then the one with smaller radius has the more abrupt canal deviation and results in higher torque on file. If two canals have the same angle of curvature but have a different radius. When an instrument is rotating around the curve. Torque also will rise with increased apical force. using a larger diameter instrument such as 0. In a relatively straight or a gently curved portion of a canal.04 taper. an intermediate taper such as 0. Flexural fracture arises from minute surface defects and occurs after cyclic fatigue [43.06 taper or a GT file. eventually. although being stronger and having better torque resistance. When encountering a sharp apical curve. Use of a lubricant within the canal can reduce the friction between the instrument and canal wall.

Peters and Barbakow [46] measured the number of rotations to failure in a cyclic fatigue test and then divided this number by the average of rotations for preparing an individual canal. may lead the instrument to repeatedly move in a forward and reverse motion. ProFile and other NiTi rotary instruments should be operated with constant speed.76 Y.04 taper instrument [46]. Kim / Dent Clin N Am 48 (2004) 69–85 file to enter the canal. S. For an experienced operator. The recommended speed for the ProFile system ranges from 250 to 350 rpm. resulting in increased cyclic fatigue [14]. high torque-control motors.-Y. The torque value for an individual instrument is set at slightly lower than the limit of elasticity. Yared and Sleiman [48] demonstrated that for an experienced operator. rotational speed within that specific range may not be as critical as for an inexperienced operator. there was no difference in the failure incidence of ProFile instruments used with air. When the instrument is rotating. Using a torque-control unit. it is advised to discard instruments after abuse in an extremely curved or narrow canal. If the motor is loaded up to the torque limit. Taking the complex anatomy of root canals and the torque generated for torsional fracture into account. instruments should be discarded after a certain number of uses [14]. Yared et al [48. Obtaining . Daugherty et al’s [50] study suggested that the ProFile 0.04 taper Series 29 rotary instruments should be used at 350 rpm to double the efficiency and halve the deformation rate compared with the 150 rpm group. using the slower speed of 150 to 170 rpm would be more likely to prevent instruments from deformation and fracture [49]. or low torque-control motors. Their result indicated that up to 5 to 10 curved canals could be safely prepared with the ProFile 0. Hsu. the motor stops momentarily or rotates backward to avoid permanent deformation and intracanal breakage [47]. and these data are preprogrammed in the machine. for an inexperienced operator. For an inexperienced operator. however. In contrast. Most important. use of the low torque-control unit can significantly reduce the incidence of intracanal breakage [48]. it should be used with gentle in-and-out movements (pecking motion) to prevent the stress from building up.49] demonstrated that use of ProFile in a crown-down manner at 350 rpm is safe for an experienced operator. however. Gambarini [47] suggested the use of low-torque endodontic motors to reduce the mechanical stress on NiTi rotary instruments. Each file is used only for a short time and should never be left rotating in a stationary position. the manufacturer of ProFile recommends that the files be discarded after 6 to 8 clinical uses. Clinical applications Cleaning and shaping of the root canal system The fundamental concepts for cleaning and shaping of a root canal system remain the same regardless of the techniques and instruments used. Because fracture of NiTi instruments can occur without evidence of unwinding and deformation.

with GG bur 4 submerging the cutting head below the orifice and each smaller GG stepping into canal for about 2 to 3 mm until reaching the predetermined depth. Ultrasonics and chelating agents such as EDTA also can be used before canal preparation. The preparation should be extended to eliminate any coronal interference during subsequent instrumentation [3]. the chamber is debrided by copious irrigation with NaOCl. it gives information about canal anatomy regarding to the curvature and width. Orifice Shapers. the clinician is ready to advance the stainless steel hand file to the apical terminus. therefore. No matter what instrument or what sequence is selected. Any overhanging dentins from the chamber roof and cervical ledges near the orifices have to be removed. Pre-enlargement of the coronal two thirds can be accomplished with a variety of instruments such as Gates-Glidden (GG) burs. In cases where canals merge (Weine’s classification type II). obturation can be accomplished without violating surrounding periradicular tissue. pre-enlargement facilitates rapid removal of contaminated tissue from the canal system and improves the penetration of irrigation solution. Mechanically. Dr.02 taper. The goals for pre-enlargement are to relocate the canal away from the anatomic danger zone and to achieve uninhibited access to the apical third of the canal. Kim / Dent Clin N Am 48 (2004) 69–85 77 a straight line access into the orifice and canal is the first critical step for successful outcome. After the coronal access is completed and canal orifices are identified. NiTi rotary instruments will bind to the dentinal wall and fracture. Preflaring also provides more accurate and consistent working length determination [39] and.38]. Pre-enlargement of the coronal two thirds of the canal has mechanical and biologic benefits. Therefore. The clinician should mentally picture the canal anatomy before use of rotary instruments. It minimizes extrusion of debris apically and subsequent post-treatment flare-ups [38]. GT files. it creates a patent pathway for the rotary instruments. and any NiTi rotary system with greater tapers in either crown down or step back manner. Second. Hsu. The entire pre-enlargement procedure should be done with copious irrigation and frequent recapitulation to ensure canal patency [3. size 15) to the level at least 2 mm deeper than the desired depth for the rotary instruments. Ruddle [3] suggested using NiTi rotary files in a crown-down technique or GG burs in a stepback technique to complete coronal preparation. Also. canals divide (Weine’s classification type IV).Y. these .-Y. The reason for hand files to reach the level 2 mm beyond the rotary instrument is to preserve the most apical canal anatomy for future hand file advancement. more precise canal cleaning and shaping. S. it is important to insert a stainless steel hand file (0. and in bayonet-shaped canals. Biologically. The advantages for such a procedure are twofold. After pre-enlargement of the coronal two thirds. yet still preserve enough root structure for prosthetic restoration. The author prefers using GG burs in a crown down direction. It also minimizes canal deviation and instrument separation by reducing contact with the canal. thus aiding in better tactile sensation of the file moving apically. First. pre-enlargement allows early removal of coronal interferences. size 10.

removal of coronal interferences with a larger file set at a shorter distance or enlargement of the pathway with a smaller file will aid in file advancement. 5. The most likely cause is encountering curvature.78 Y.04/30 for larger canal).04/30. ProFile and other NiTi rotary instruments will perform optimally with less breakage when used with the recommended speeds and correct sequences. Create a glide path with a size 10/15 stainless steel K file. 4. and 1 in the coronal one third based on canal size and angle of pathway. In either case. Perform apical preparation with ProFile taper/size 0.06/30. Use Orifice Shapers sizes 4. The clinician should keep the instrument rotating before entering the orifice and use a short-distance pecking motion to advance the file apically. Obturation After complete cleaning and shaping of the root canal system. the obturation procedure can be proceeded when no subjective symptoms or Box 1. the principles remain the same. If resistance is confronted. Another possibility for resistance is intracanal or interblade debris accumulation. Perform crown-down preparation: use ProFile instrument of taper/size 0. .06/25 short of working length to blend the coronal and apical preparation. Copious irrigation with recapitulation or wiping the debris off the file with wet gauze or a sponge will resolve the problem. Only after a patent pathway to the terminus is established by using small hand files should the clinician start finishing the apical preparation with a rotary instrument. Estimate the working length of the canal from a preoperative radiograph.04/25 to resistance (0. so long as the instruments are used passively within the canal. Recommended sequences for use of ProFile by manufacturer 1.04/25. Kim / Dent Clin N Am 48 (2004) 69–85 difficult anatomies are better finished with hand instrumentation. 7.06/30. Determine the working length with size 15 K file. 0. Hsu. S.04/30. 0.06/35. Several possibilities exist for the resistance of apical movement. 0. however. Although the philosophies may vary. 2. 3. then the file should be withdrawn while rotating.04/35. 0. 2. 2) may not be critical. Whether the sequence is from large to small or vice versa (Boxes 1. the instrument tip may be too big to follow the pathway established by the small hand file. The apical extension of working length and the final apical preparation size have long been debated. 0. and 0. and 0. 3. 6.-Y. Accurate working lengths can be obtained from well-angulated radiographs and an electronic apex locator [39].06/25. Finish with ProFile taper/size 0.

5. the use of greater taper cones such as 0. The obturation quality and efficiency of the cold lateral compaction technique were evaluated by Hembrough et al [51] after canal preparation with 0. Any technique in which a clinician is proficient can be used for NiTi instrument–prepared canals. a 0.04 taper and Thermafil. The canal preparation by ProFile provides good taper and smooth flow. or GT files and corresponding GT obturators. 6.06/30.06/25. 7. 2. Estimate the working length of the canal from a preoperative radiograph. Possible sequences for use of ProFile 1. 2. The clinician should select two to three appropriately sized ProFile instruments that fit passively in the canal in a crown-down manner.02/15. and an ISO standardized cone. Perform hand instrumentation with taper/size 0. and 1 in the coronal two thirds based on canal size and angle of pathway. Kim / Dent Clin N Am 48 (2004) 69–85 79 Box 2. Figs. Retreatment ProFile instruments rotating at higher speeds are very effective tools for removing intracanal gutta-percha. 3.06 taper ProFile instruments. significant infections exist. Perform apical preparation with ProFile taper/size 0.06 taper cones and customized cones was more efficient than the ISO standardized cones because less accessory points were used [51]. 1–3 provide some examples of endodontics performed with 0.Y. Three different master cones with different degrees of taper were chosen. 3.06. a customized point from nonstandardized master cone. 0. There was no significant difference in terms of obturation quality.06 taper gutta-percha cone. There is no one particular obturation technique that is superior to others for those canals prepared with ProFile systems. Vertical compaction of warm guttapercha using traditional Schilder’s technique or the continuous wave technique achieves good clinical results. S. Create a glide path with a size 10/15 stainless steel K file. namely. The . 0. Finish with ProFile taper/size 0. The recommended speed for gutta-percha removal ranges between 1200 and 1500 rpm.02/20 stainless steel K file to working length. thus allowing uneventful plugger penetration and gutta-percha flow.06 taper ProFile files.-Y.04 and 0.35 short of working length to blend the coronal and apical preparation. which can be removed by GG burs or by heat. however. Hsu. The manufacturer advocates packages that combine rotary files and integrated obturation systems such as ProFile 0. The gutta percha near the orifice area is generally the tightest part. Use GG burs 4. Determine the working length with size 15 K file. 4.

06 taper ProFile in a gently curved maxillary second molar.80 Y. . They found that ProFile could reach ideal working length rapidly regardless of the obturation techniques but was inadequate in complete removal of gutta-percha. Hsu. With the aid of a microscope. (A. Baratto and colleagues [53] evaluated the effectiveness of the ProFile 0. friction generated by ProFile instruments can soften the gutta percha and move it coronally [52].04 taper to remove gutta-percha. 1. the clinician can try to ‘‘wipe’’ or ‘‘wick out’’ the residual gutta percha from the canal aberrations with paper points. To ensure the complete removal of gutta percha. S. Kim / Dent Clin N Am 48 (2004) 69–85 Fig.-Y. Summary NiTi rotary instruments have advanced endodontics into another era.B) Prepared with 0. The ProFile rotary instrument system has good clinical performance in managing curved canals and has proved to be more efficient than hand instrumentation. thus providing space for chemical solvent. the clinician might use ProFile to remove the bulk of gutta-percha. Our professional responsibilities include making the best use of this system and providing the best quality of care to our patients.

04 taper ProFile in a moderately curved mandibular second molar. Noted that a separated #10 K hand file in the apical third of distal canal. which was bypassed and filled to the apex. Kim / Dent Clin N Am 48 (2004) 69–85 81 Fig.-Y. Hsu. . (A–C) Prepared with 0. 2.Y. S.

Practice on the extracted teeth before use in vivo. For an inexperienced operator. . There is a learning curve before proficiency and ProFile use must follow the principles listed below [3]: 1. abrupt curvature. 3. Make sure to always have enough lubrication in the canal and work passively on rotary files. S. Kim / Dent Clin N Am 48 (2004) 69–85 Fig. Coronal and radicular straight line access are essential to proper cleaning and shaping and to reduce risk of instrument separation. Never force the instrument to advance apically. Hsu. Always use hand instrument to explore canal anatomy and obtain a pathway before introducing rotary instruments. Difficult canal anatomy such as canal merge. 5.-Y. 3. Adhere to the recommended rotational speed. Prepared with 0. Understand the limitation of NiTi rotary instruments.06 taper ProFile. 2. 4. following the sequences provided by the manufacturer may result in less frustration. and bayonet-shaped canals may not be appropriate for their use.82 Y.

Y.-Y. Hsu, S. Kim / Dent Clin N Am 48 (2004) 69–85

83

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Dent Clin N Am 48 (2004) 87–111

ProTaper NT system
Thomas Clauder, DDSa,b,*, Michael A. Baumann,
DDS, PhD, Univ.-Prof. Dr. med. dent.c
a

Department of Endodontics, University of Pennsylvania, School of Dental Medicine,
240 South 40th Street, Philadelphia, PA 19104-6030, USA
b
Private Practice, Rahlstedter Bahnhofstrasse 33, 22143 Hamburg, Germany
c
Dental School, Department of Operative Dentistry and Periodontology,
Kerpener Strasse 32, 50931 Ko¨ln, Germany

During the last decade, endodontic therapy went through a fascinating
development. The introduction of operating microscopes, rotating nickeltitanium instruments, and other new features has enabled the practitioner to
better shape the root canal. The ProTaper system (Dentsply/Maillefer,
Ballaigues, Switzerland) represents a new generation of NiTi instruments
currently available. The system was developed by a group of well-respected
endodontists (Prof. Pierre Machtou, Universite´ Paris, France; Dr. Clifford
Ruddle, Santa Barbara, California, USA; and Prof. John West, University
of Washington, Seattle, Washington and Boston University, Boston,
Massachusetts, USA) in cooperation with Dentsply/Maillefer. Compared
with other systems, the files demonstrate completely new design features.
The progressively tapered instruments with their new flute design and their
clinical use are described below in detail [1].
Proper biomechanic cleaning and shaping of the root canal system is the
basis of endodontic therapy and three-dimensional obturation. Since the
introduction of the first rotating nickel-titanium files for the preparation of
root canal systems in endodontics, a wide range of new file systems have
been established in the market. The benefits of the new systems are apparent
in their near-perfect preparation of the root canal system. Properly used,
NiTi systems enable the user to finish a more predictable root canal
instrumentation and limit procedural errors at the same time. The latest
research [2,3] seems to confirm the fact that NiTi files are easing the
preparation with no or very little transportation.

* Corresponding author. Rahlstedter Bahnhofstrasse 33, 22143 Hamburg, Germany.
E-mail address: praxis_clauder@t-online.de (T. Clauder).
0011-8532/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.10.006

88

T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87–111

Originally, NiTi ProTaper instruments were developed to facilitate
instrumentation of difficult, constricted, and severely curved canals (Fig. 1).
A revolutionary new file geometry was designed to allow for high efficiency
and safety. Since the introduction of the system, the continuing application
has allowed for the safe and efficient management of even ‘‘standard-cases’’
(Fig. 2). The ProTaper instruments were designed ‘‘to cover the whole range
of treatment with only a few files, which incorporate superior flexibility,
unmatched efficiency and improved safety’’ [1]. The number of files with
a progressive taper (ProTaper) was decreased to a set of six instruments
(Fig. 3): three shaping files for the crown-down procedure and three
finishing files for apical shaping and creating a smooth transition from the
middle one third of the canal providing the preparation deep shape. The
three shaping files are characterized by increasing tapers over the whole
length of their cutting blades, allowing for a controlled cutting performance
in special sections of the instrumented root canal. The finishing files are
dominated by different diameters, #20, #25, #30 and a fixed taper over 3 mm
to finish apical preparation.

Fig. 1. Radiograph showing a severely curved upper premolar with two joining canals.
(Courtesy of Thomas Clauder, DDS.)

T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87–111

89

Fig. 2. This tooth was cleaned and shaped with ProTaper files. (Courtesy of Thomas Clauder,
DDS.)

The following innovations characterize the ProTaper system:
Progressive taper
Modified guiding tip
Varying tip diameters
New cross-section of the instruments
Varying helical angel and pitches
New shorter handle of the file
One of the most outstanding innovations is the varying taper within one
file. Comparing the ProTaper NT system with other systems, one can note
that other file systems focus on one taper within a file and tend to combine
a series of files to achieve the necessary effect. In contrast, ProTaper has
varying tapers within one file ranging from 3.5% to 19%, which makes it
possible to shape specific sections of a root canal with one file. Other new
design features are the modified guiding tip (Figs. 4 and 5) and varying tip
diameters. The modified guiding tip allows one to follow the canal better
and the variable tip diameters allow the files specific cutting action in defined
areas of the canal, without stressing the instrument in other sections. In

Clauder. ProTaper—a new generation of NiTi-files in endodontics.90 T. 6).) . triangular cross-section (Fig. Endodontie 2001. Baumann / Dent Clin N Am 48 (2004) 87–111 Fig. This design results in a reduced contact area between dentin and the cutting blade of the instrument. M. Scanning electron microscope (SEM) picture demonstrating the modified guiding tip of a ProTaper file.10:353. The set of six ProTaper files includes three shaping files and three finishing files.A. 4. (From Baumann MA. 3. achieving Fig. with permission. comparison with other file systems manufactured by Dentsply/Maillefer (Profile and System GT) as well as other file systems with radial lands and a U-shape design. ProTaper instruments demonstrate a new convex.

it is possible to reduce the torsional strain and ease the pressure to achieve widening of the root canal. with permission. SEM picture demonstrating the cutting blades of a ProTaper file. 7 and 8).) . SEM picture demonstrating the convex. which substantially increases the effectiveness of the system and reduces torsional strain [4]. triangular cross-section of the ProTaper files. Endodontie 2001.T. Regarding instrument geometries. 6. Clauder. only F3 has a reduced cross-section with a U-shape to facilitate a higher degree of flexibility (Figs. In comparison with other file geometries with radial lands that produce a passive cutting and scraping action. (From Baumann MA. Fig. M. the ProTaper system works with an active cutting motion. 5.) cutting efficiency that was not possible previously.10:353. ProTaper—a new generation of NiTi-files in endodontics.A. Baumann / Dent Clin N Am 48 (2004) 87–111 91 Fig. ProTaper—a new generation of NiTi-files in endodontics. Endodontie 2001. with permission. In the same process. (From Baumann MA.10:353.

10:353.54 mm to allow for better access in difficult Fig. M. with permission. Baumann / Dent Clin N Am 48 (2004) 87–111 Fig.10:353. (From Baumann MA. allow for better removal of debris out of the root canal. 7. The length of the file handle of the instruments was reduced from 15 mm to 12. ProTaper—a new generation of NiTi-files in endodontics. and prevent the instrument from screwing into the canal.A. SEM picture demonstrating the cutting blades of F3 with a reduced core. Endodontie 2001. Clauder. Endodontie 2001. which improve cutting action.) . with permission.) Furthermore. ProTaper—a new generation of NiTi-files in endodontics. (From Baumann MA. SEM picture demonstrating the cross-section of F3 with a reduced core.92 T. new design features are the variable helical angel and balanced pitches in the instrument. 8.

posterior areas. The files are available in 21. M.T. Instrument design Shaping files The ProTaper system features six NiTi files.A. called Shaper X or SX. This graphic model. (Courtesy of Thomas Clauder. the first of which is the auxiliary shaping file. 9. Pierre Machtou—one of the three specialists involved in the development of Fig.and 25-mm lengths. 10. which could compromise the treatment result. shows the complex design of the instruments. Straight-line access is of major importance. especially in complex canal systems such as the obturated c-shaped lower molar. reminding Prof. Clauder. overlapping the taper of ProTaper instruments. DDS. Baumann / Dent Clin N Am 48 (2004) 87–111 93 Fig.) . SX is recognized by its lack of an identification ring on its handle and its extraordinary shape.

and 1. DDS. the canal orifice has to be relocated to achieve straight-line access to the apical region of the canal. and 19%.5% to 19%. the cross-sectional diameter increases from 0.A. With brushing motions. respectively.) the system—of the Eiffel Tower in Paris (see Fig. Fig. D8. 17%. (Courtesy of Clifford J. 12. Ruddle. Ruddle.) . Baumann / Dent Clin N Am 48 (2004) 87–111 Fig. 11. SX is available with cutting blades of 14 mm and a tip diameter of 0.10 mm. (Courtesy of Clifford J. and D9. Clauder.90 mm. At D6.94 T. 14. M.70 mm. according to a taper of 11%.50 mm. The file in the unshaped canal gives information about the angulation of the coronal part of the canal. All of the ProTaper shaping files have a progressively increasing taper. The total increase of taper in SX from D0 to D9 is defined with nine different tapers from 3. 0.19 mm. SX has the highest increase. D7. 3).5%. DDS. 0.

Fig. Clauder. Baumann / Dent Clin N Am 48 (2004) 87–111 95 Fig. (Courtesy of Clifford J. Precise determination of working length and establishing patency with hand files are key factors for further cleaning and shaping procedures. DDS.) .) The complex file design allows for ideal and efficient shaping of the coronal aspects of the root canal and the relocation of canal orifices. Shaping with SX leads to removal of the overlapping dentin walls and allows for straight-line access. The instrument is used in a brushing motion and is designed to replace Gates-Glidden drills (Dentsply Maillefer. M. resulting in a straight-line access. 13. where strip perforations can compromise treatment objectives.A.T. Ruddle. The relocation of the canal orifices should be in the direction of overhanging dentin areas and away from ‘‘danger zones’’ in furcation areas and thinner dentin walls. (Courtesy of Clifford J. Ruddle. 14. DDS.

Clauder. Baumann / Dent Clin N Am 48 (2004) 87–111 Fig. 15.96 T.20 mm. which corresponds to a Gates-Glidden drill size of four. 16.11 mm.) . S1 has an increasing taper from 2% on D1 to Fig. 3). S1 and S2 are carried to working length. Ruddle. Shaping file 1 (S1) has a purple identification ring and shaping file 2 (S2) has a white identification ring on their handles (see Fig. although the increase is not as aggressive as that of SX.19 mm and of S2 is 0. DDS. (Courtesy of Clifford J. shaping primarily the coronal two thirds of the canal. M. Switzerland). Ruddle.) Ballaigues. (Courtesy of Clifford J.A. but also pre-enlarging the apical area. The diameter at D10 is 1. Both instruments have an increasing taper over the whole working range. The diameter at the tip of S1 is 0. Gauging the apical canal diameter provides further information that influences the finishing criteria. DDS.

Radiograph showing a curved lower molar instrumented with ProTaper rotary files. 17. (Courtesy of Thomas Clauder.A. engage special sections of the root canal shown in the graphic. 18. ProTaper files.T. Fig. Clauder. Baumann / Dent Clin N Am 48 (2004) 87–111 97 Fig. DDS. M. used in the described sequence.) .

and F3 are marked with a yellow. All three instruments have a fixed taper in the first 3 mm from D0 to D3. 3). visible deformation or defect.25 mm. allowing for a clean.30 mm. The instruments have been developed for superior apical preparation. F1 has a taper of 7%. shaping.A. Clauder. Force should never be applied to . respectively. in addition to shaping the middle section preferably. instruments may break without warning or any indication of a previous. red.20 mm. a reverse taper can be found. Baumann / Dent Clin N Am 48 (2004) 87–111 11% on D14. Although experience and routine is of great importance to the successful usage of the system [8]. These fractures often occur in the apical portion of the root canal system. the risk of instrument separation increases. Finishing files The finishing files F1. 0. even experienced operators can reduce the risk of separation by working with the recommended range of torque. respectively (see Fig. 9) [5]. The decreasing taper ensures a continuing flexibility within the file and avoids too large a diameter at the shaft area of the instrument. permanent. S2 has an increasing taper from 4% on D1 to 11. The successful application of the system demands certain preconditions. Over the remaining length of the cutting blade. and 0. To minimize this risk of separation.5% on D14. they shape the apical region increasingly (doubling of the taper at the instrument tip). Although the manufacturers of NiTi systems recommend checking the files frequently to prevent possible fracture. efficient. and blue identification ring. S2 is designed to shape the middle section of the root canal system. The use of new instruments also reduces the risk of instrument fracture significantly [9].98 T. in comparison. M. and predictable preparation of the root canal. Because these instruments are already at working length after initial preflaring. Instrumentation with ProTaper files The ProTaper system is a preparation system that can be used for complex and standard cases. F2. and F3 has a taper of 9% in this region. impeding adequate cleaning. S1 is designed to shape mainly in the coronal section of the root canal. This complex and demanding instrument design can be appreciated best when comparing the cross-sections in an overlapping model highlighting the tapers graphically (Fig. Their diameters at the tip (D0) are 0. F2 has a taper of 8%. and obturation. it is recommended that inexperienced users take advantage of torque-controlled endodontic motors [7]. Torque-controlled endodontic motors Ruddle [6] has shown that with the use of rotating NiTi instruments.

it is necessary to achieve a straight-line access and to reduce all overlapping dentin areas. 19.) a file.10]. access cavities should be reshaped so that a straight-line access to apical regions can be achieved.T. Baumann / Dent Clin N Am 48 (2004) 87–111 99 Fig. (Courtesy of Thomas Clauder. ProTaper files were used for hand instrumentation to instrument the extreme curvature of the lower molar. independent from the file system and the technique used (Fig. it has to be ensured that all orifices can be viewed on the mirror without any movement of it. The angulations after the initial crown down should be parallel to the axis of the tooth to ensure the most effective cutting efficiency in the regions of application. and safely [1. the instrument should stand upright (Fig. M. 10). The ProTaper SX file may be used to remove the triangle of dentin rapidly. Straight-line access An ideal access cavity preparation is very important to successful treatment.A. A recent study showed that the ProTaper System—like most other rotational . effectively. Clauder. The angle of the inserted instrument is a good indicator: if straight-line access has been achieved. DDS. only a light brushing motion should be used to achieve the desired results. Furthermore. In addition. To avoid staining the files unnecessarily and instrumenting unnecessary curvatures. 11) [1].

(Courtesy of Thomas Clauder. and also is necessary for the safe use of the ProTaper System. A wellprepared coronal shaping minimizes this problem and therefore is of utmost importance to a successful result [11]. Baumann / Dent Clin N Am 48 (2004) 87–111 Fig.A. A carefully prepared glide path allows for the safe use of the instrument. M. and also widen the apical portion of the canal [7]. Clauder. The following instruments engage different parts of the canal system as far as their instrument geometry allows. The ProTaper system is designed so that the files—after initial preflaring with S1 and SX—can be carried easily to working length. 20. Glide path Establishing a smooth glide path is a top priority for all endodontic manipulations. Irrigation and chelators The pulp chamber has to be filled with irrigating solution (NaOCl or ethylenediaminetetraacetic acid [EDTA] solution) during the whole shaping . which increases when the root canal systems show an increased initial angulation [11]. DDS. Previous endodontic treatment resulted in persisting apical periodontitis and is a source of acute symptoms.) systems—tends to result in slight transportation.100 T.

severe curvatures. 21.) procedure. irrigation confirming patency and reirrigation is of main importance. (Courtesy of Thomas Clauder.A. or s bends [12]. S1 is the first instrument used. Additional knowledge also can be gathered on the anatomy of the canal and potential anatomic problems that could influence the treatment plan. a brushing motion against the canal wall in the direction of repositioning the canal orifice is used. Coronal . a viscous chelator should be used to minimize force on the instrument. such as confluent or dividing canals. and important information can be deduced from the angle of the canal and the confirmation of straight-line access (see Fig. 11). or complete calcified canals are present. After a glide path has been established with K-files. This motion is repeated a few times before removing the file from the canal. The ProTaper files also can be used for retreatment cases.T. constricted. This is a decisive step in the use of any rotary system. After the use of each instrument. A further aspect is the canal diameter—the procedure is influenced substantially when open. DDS. This postoperative radiograph shows the tooth after instrumentation and obturation of all four canals. During insertion. One of the first steps after carefully preparing an ideal access cavity to working length is the initial negotiation of the canals with a #10 or #15 K-file up to about two thirds of the estimated working length. Clauder. M. Baumann / Dent Clin N Am 48 (2004) 87–111 101 Fig. In addition.

SX is inserted while rotating into the root canal.) shaping with SX then can be started. Clauder. After the initial crown down is finished. Working length should be checked with an electronic apex locator and confirmed with a well-angulated radiograph. 12) [1. Patency is of great importance and must be maintained during the complete shaping procedure . 14). Shaping with SX should result in generous dentin removal. After the initial crown down. 13). inadequate widening of the coronal aspects of the root canal can complicate and slow down further instrumentation. This interesting canal anatomy was cleaned and shaped with ProTaper files. If a light resistance is felt on the instrument. the files inserted into the root canal should be parallel to the axis of the root (Fig.6]. Deformed instruments must be discarded immediately. A #10 K-file is inserted passively into the canal.A. the file is withdrawn and worked in a brushing motion against the dentin wall of choice (Fig. 22. the working length is confirmed and patency is established (Fig. Repeating this procedure allows for deeper insertion of the instrument.102 T. enabling the removal of all overlapping dentinal walls and a perfect coronal shape of the root canal. M. DDS. It is important to inspect the instrument after each use to prevent fractures of the instrument. Baumann / Dent Clin N Am 48 (2004) 87–111 Fig. because following instruments can get stuck in thin coronal parts of the canal. (Courtesy of Thomas Clauder.

confirming patency. Widening the apical portion seems to reduce the risk of fracture in constricted. In this case. The coronal aspect of the root canal has not been widened enough. 23. SX should be used . S1 is moved carefully to working length in a brushing technique.A. M. Baumann / Dent Clin N Am 48 (2004) 87–111 103 Fig. ‘‘Straight forward cases’’ can be shaped without procedural errors. The ProTaper system usually works very efficiently and reliably. the shaping procedure with ProTaper instruments is continued. Clauder. If this goal cannot be achieved or can be achieved only by forcing the instrument.) [10]. The flutes are covered with debris and dentin chips.13]. continuing the shaping procedure by hand instrumentation is the method of choice. In most cases. Efficiency decreases rapidly when the flutes of the instrument are blocked with debris. which occurs most often in long canals. and repeating the last step usually solves these problems. In all other situations. (Courtesy of Thomas Clauder. narrow canals [10. an initial apical instrumentation with hand instruments to a size of #15 K-files is necessary and very important. there are several possibilities that can prevent the file from moving to apical areas: 1. DDS. irrigating the canal. 2.T. in which it is likely that the use of rotary instrumentation will result in failure. In special cases with complex anatomic structures. Cleaning the instrument thoroughly.

) in a more effective way or. The canal should be instrumented by hand to an appropriate size to reduce the torsional load on the instrument. M. The lower molar was shaped for three-dimensional obturation of the root canals. The canal is obstructed in apical areas. 24. Apical . The fact that a canal is very tight or calcified can be detected by scouting the apical portion of the canal and establishing working length. The canal is blocked by dentin chips or pulp tissue in the apical portion.A. 3. Gates Glidden drills can help to widen the coronal and middle portion of the canal to prevent following files from blocking in these areas. S2 is used in one or two strokes to working length in the same manner as described previously (Fig. 4. DDS. Clauder. patency should be established with an adequate K-file.104 T. Blockage of a rotating instrument in the apical tight canal leads to extreme torsional loads on the instrument and high risk of separation. 15). The coronal two thirds of the root canal now should be shaped ideally. as an alternative in very long canals. A viscous chelator (EDTA solution) should be irrigated into the canal. (Courtesy of Thomas Clauder. After successful insertion of S1. and the instrumentation should be repeated with smaller files. Baumann / Dent Clin N Am 48 (2004) 87–111 Fig.

With the second use of S1. like this premolar with three roots. 25. Does the #25 K-file bind at working length preparation of the root canal is finished.T. F2 is inserted to working length. M. The last instrument reaching working length is S2.) preparation is done with the finishing files. DDS. (Courtesy of Thomas Clauder. Anatomic variations. Apical gauging should be repeated now with a #30 K-file (Fig. which has a diameter of 0. Due to the design of the file.20 mm at the instrument tip and a taper of 4%. attention is given to maintain working length. the preparation is finished. F1. if the file is loose in the canal. Apical gauging should be repeated now with a #25 K-file. During this procedure. Clauder. 16). Does the #30 K-file bind at working length preparation of the root canal is finished.A. The apical diameter of the root canal is gauged with a #20 K-file. The instrument is inserted passively into the canal to working length. Clifford Ruddle is as follows [12]. which has the same diameter at the instrument tip. tapping on the head of the instrument to prevent cutting action. If the file is loose in the canal. If the file binds in the apical region. if the file is loose in the canal a different technique should be chosen to finish apical preparation. For apical gauging and shaping the technique preferred by Dr. Baumann / Dent Clin N Am 48 (2004) 87–111 105 Fig. all . can be worked to working length. F3 should be used to working length. a uniform taper of 7% is produced in the apical portion of the root canal. can be introduced with the system.

the use of ProTaper files in a hand file manner is helpful.36:87. ProTaper rotary root canal preparation: effects of canal anatomy on final shape analyzed by microCT.) instruments are inserted to working length. During the complete shaping procedure. the lifespan of an instrument is directly proportional to a specific number of rotary cycles [16]. and effective antibacterial protocol. without significant transportation of the original position. The order of instrumentation and the varying areas of use for each ProTaper file are shown in Fig. 26. Barbakov F. The micro-CT evaluation demonstrates the canal anatomy of an upper molar before instrumentation. Cutting efficiency can be improved in a turning motion. Baumann / Dent Clin N Am 48 (2004) 87–111 Fig. establishing patency and reirrigation is of extreme importance to achieve perfect cleaning and shaping objectives. Clauder. Scho¨neberger K. 19). focus also should be given to maintaining an accurate. The ProTaper files engage specific sections of the root canal system. In cases of severe curvatures. 17. (From Peters OA. as the instrument geometry and design allows. inspecting the instruments for debris remnants immediately after use. especially because there are new useful handles available (Dentsply/Maillefer). precise. Int Endod J 2003. ProTaper instruments provide a continuous tapered preparation of the root canal. After each instrument irrigation. In cases of pronounced and acute curvatures [17] with a small radius (Fig. ProTaper . The files can be used safely in a watch-winding motion. M. In addition. This can be demonstrated very easily.15] (Fig. rotational speed of the instruments could be reduced to a minimum of 150 rotations per minute [14. Peters CI.A. 18).106 T. with permission.

.36:87. Spreaders and pluggers with 0. 27. 20 and 21). Clauder. Summary Root canal instrumentation should provide a tapered. 22 and 23). allowing for a thorough irrigation technique. Peters CI. the finishing files are especially useful in the careful removal of gutta percha. (From Peters OA. The well-planned file design allows for an ideally prepared root canal of easy or difficult shape (Figs. if pretreatment did not result in far greater apical diameters (Figs. adequate canal shape to allow for effective irrigation and obturation [18]. ProTaper rotary root canal preparation: effects of canal anatomy on final shape analyzed by microCT. M. with permission. Scho¨neberger K. Barbakov F.T. Baumann / Dent Clin N Am 48 (2004) 87–111 107 Fig. The finish of the root canal instrumentation allows for a predictable obturation of the root canal system.50-mm tips can be used readily during obturation of root canals with such apical preparations [11].A. They also can be used for antibacterial therapy.65 mm to 0. the instruments can be used in the previous described sequence. This can be accomplished thoroughly with the ProTaper NiTi system (Figs. 24 and 25). with sizes varying from 0. ProTaper instruments adequately open canals 5 mm from their apices. The micro-CT evaluation demonstrates the canal anatomy of an upper molar after cleaning and shaping procedures with ProTaper files.) instruments can be helpful in retreatment cases. independent of technique chosen. For reshaping the canal anatomy after establishing patency.79 mm. Int Endod J 2003.

with permission. A prolonged rotation of the instrument with an active cutting blade can lead to unnecessary misshapes in canal anatomy.A. 29). The latest evidence shows that ‘‘canals can be prepared with the ProTaper system without major procedural errors’’ (Figs. .19].36:89.) After the ProTaper system was introduced. Another study [19] has shown no transportation in the middle section of the tooth and in apical areas. (From Peters OA. Micro-CT evaluation of shaped canal studies showed that the ProTaper System tends to transport canals slightly larger than do file systems with a passive cutting action [11].108 T. M. Superimposing pre. but obviously is not as severe as with a standardized instrumentation technique using stainless steal instruments [3]. Barbakov F. and little transportation in coronal areas toward furcation areas. the possibility of more or less severe canal transportation produced by active cutting action was discussed. Peters CI. 28. Clauder. Therefore. it is important to immediately remove the instrument out of the root canal once working length is achieved. Baumann / Dent Clin N Am 48 (2004) 87–111 Fig. This tendency can be minimized by achieving proper coronal shaping and straight-line access (Fig. Int Endod J 2003. A center displacement toward the furcation area also has been demonstrated with several NiTi systems on the market [19]. Straight-line access helps to minimize transportation during the shaping procedure [11]. 26–28) [11. ProTaper rotary root canal preparation: effects of canal anatomy on final shape analyzed by microCT.and postoperative data demonstrates the shape created with ProTaper files following canal anatomy. Scho¨neberger K.

Constricted canals are a major problem because of the correlation with high torque values. Baumann / Dent Clin N Am 48 (2004) 87–111 109 Fig. M. Sections of treated extracted teeth with ProTaper instruments show a centered preparation allowing for complete obturation. high forces that are generated in some cases of constricted canals were insufficient to fracture ProTaper instruments [13].A. Furthermore. The ProTaper files generate lower torque scores than do rotary instruments with a U-file design (radial land).T. 29. Clauder. Using a ProTaper file .

. Int Endod J 2002. [9] Gambarini G. This is discussed in the article on hybridization of file systems elsewhere in this issue.5(3):15–24. Kulkarni GK. Brown DC. 8th edition. [10] Ruddle CJ. Machtou P. References [1] Ruddle CJ. Int Endod J 2001. The ProTaper technique. [6] Ruddle CJ. Effects of four NiTi preparation techniques on root canal geometry assessed by micro computed tomography. Int Endod J 2001. The ProTaper endodontic system. 231–91. [5] Baumann MA. Peters CI. [7] Yared GM. Vulcain JM. Int Endod J 2001. Pathways of the pulp. Mathematic models have confirmed that in case of similar apical loads. Endodontie 2001. Recent studies have shown that the ProTaper system perfectly shapes curved and constricted canals [11. Finishing the apical one-third. Influence of rotational speed. The system enables a safe of time compared with hand instrumentation techniques. J Endod 2001. Endod Prac 2002. In: Cohen S. 2001. [4] Turpin YL. Int Endod J 2003. Cyclic fatigue of ProFile instruments after prolonged clinical use. Scho¨neberger K.34:386–9. which is apparent as the design features and sizes available suite less [11].10(4):351–64. Bou Dagher FE. Apical instrumentation with K-files is extremely important in these cases. [12] Ruddle CJ. In more difficult cases. [13] Peters OA. In addition. Cleaning and shaping root canal systems. Baumann / Dent Clin N Am 48 (2004) 87–111 seems to minimize fracture risk of the instrument [13]. Combining ProTaper system with other NiTi systems emphasize the advantages of the ProTaper system can provide larger apical sizes. ProTaper rotary root canal preparation: assessment of torque and force in relation to canal anatomy. Bou Dagher FE.27:333–6.110 T. Wide canals were less efficiently instrumented.5:22–30. Clauder. Int Endod J 2001. Influence of rotational speed. Scho¨neberger K.36:93–9. Cathelineau G. the scientific background. The operator should decide on the size of the apical instrumentation according to the preferred treatment concept. [3] Gluskin AH. allowing for high performance and less risk [20].15]. Burns RC. Laib A. Chagneau F. ProTaper—Eine neue Generation von Ni-Ti-Feilen [ProTaper—a new generation of NiTi-files in endodontics]. Peters CI. Barbakov F. Scho¨neberger K.35:7–12. [11] Peters OA.13. Bartier O. Impact of torsional and bending inertia on root canal instruments. especially in simple and predictable cases. St. [2] Peters OA. Louis: CV Mosby.34:47–53. [8] Yared GM. the advantage lies in the perfect preparation of the root canal. ProTaper rotary root canal preparation: effects of canal anatomy on final shape analyzed by microCT.34:221–30. If the apical regions are to be enlarged wider than ISO 30 in large canals. Endod Prac 2002. editors. Buchanan LS. and the special case selected. discarding instruments—after or during use—that have been used in calcified canals helps to minimize the fracture risk of the instrument.5(1):34–44. Machtou P.34:476–84.A. torque and operator proficiency on ProFile failures. it might be best to use a different technique to achieve the treatment goal rather than using the ProTaper system. M. Int Endod J 2003. Barbakov F. ProTaper instruments work longer in a super elastic phase than do instruments with a U-file design. p. Endod Prac 2002. torque and operator proficiency on failure of greater taper files.36:86–92. A reconstructed computerized tomographic comparison of Ni-Ti rotary GT files versus traditional instruments in canals shaped by novice operators.

.T. M. 1984. Ibba A. Progressive versus constant tapered shaft design using NiTi rotary instruments. [16] Yared GM. 3rd edition. Cyclic fatigue testing of nickel-titanium endodontic instruments. St. Maga´n F. Varela P. Baumann / Dent Clin N Am 48 (2004) 87–111 111 [14] Martin B. Carnes DL. Comparative analysis of torsional and bending stresses in two mathematical models of nickel-titanium rotary instruments: ProTaper versus Profile. Burns RC. Chiandussi G. Int Endod J 2003. Lambrechts P. Ahn S. Wevers M. Bou Dagher FE.36:288–95. Magan F. Varela P. Bavaglio I. Clement DJ.28:540–2. Ahn S. [18] Schilder H. Martin B. Int Endod J 2003. Bahı´ llo JG.A.36:262–6. Clauder. Factors influencing the fracture of nickel-titanium rotary instruments. Int Endod J 1999. J Endod 1997. J Endod 2002. Canal debridement and desinfection.29:15–9.23:77–85. Beullens M. [15] Zelada G. Louis: CV Mosby. The effect of rotational speed and the curvature of root canals on the breakage of rotary endodontic instruments. Zelada G. [19] Bergmanns L.32:115–9. Van Meerbeeek B. Machtou P. p. [17] Pruett JP. et al. 175. Pathways of the pulp. editors. J Endod 2003. Van Cleynenbreugel J. Cyclic fatigue of ProFile rotary instruments after simulated clinical use. In: Cohen S. [20] Berutti E. Bahillo JG. Yee FS.

Progress in file development stagnated somewhat until the mid-1980s when the balanced force technique and its associated files were described [2]. short cutting heads. All rights reserved. Traditionally. One was the use of nickel-titanium to manufacture hand instruments and the second was the development of an innovative engine-driven instrument. BDS. Design of lightspeed instruments LightSpeed instruments are quite unique. 1976) and obtained international recognition (International Standards Organization [ISO] status) in 1981 [1]. The unique features include their sizes.10. Plattenstrasse 11 CH-8028. Specifications and tolerances for hand files currently comply with American Dental Association Specification No.4]. Switzerland Successful endodontic therapy calls for optimized chemomechanical preparation of root canals. 1). the Canal Master U (Brasseler.cden. Periodontology and Cariology. HdipDent.Dent Clin N Am 48 (2004) 113–135 The LightSpeed System Fred Barbakow. noncutting. Until approximately 10 years ago. taperless shafts (Fig. disinfection where required. School of Dentistry. most root canals were prepared by hand instruments whose basic design was patented by the Kerr Co. in 1915 and comprised a 2% taper with 16-mm-long cutting surfaces [1]. E-mail address: fred.see front matter Ó 2004 Elsevier Inc. San Antonio. engine-driven endodontic instruments with this innovative design were manufactured from nickel-titanium and were marketed as LightSpeed instruments (LightSpeed Endodontics. and placement of a leakage-free coronal restoration. and long. Zurich. doi:10. MSc (Med) Department of Preventive Dentistry. Subsequently. Texas).barbakow@zzmk. 28 (Council of Dental Materials and Devices.003 . University of Zurich. root canals are prepared using stainless-steel hand files and reamers. thus.2003. Savannah. Georgia) [3.1016/j. Changes in canal preparation evolved rapidly when two innovative concepts developed independently of each other during the late 1980s. oburation.unizh. it is important to describe the innovative features that make up the instrument.ch 0011-8532/04/$ .

Cutting heads LightSpeed cutting heads are designed to operate in a continuous clockwise rotation and have three radial lands and three U-shaped spiral . between sizes 25 and 30.5. These markings or rings are important. and 65. because it is impossible to identify the full size from its corresponding half-size by color alone. which fit between sizes 55 and 60 and between sizes 60 and 70. The half-sizes are color-coded exactly as the previous size. 32. Switzerland) (right) with its 16-mm-long cutting surface. In addition to the color-coded full ISO sizes. placing sizes 22. 27.114 F. 1. Ballaigues. and between sizes 30 and 35. The last two half-sizes are sizes 57. 25 mm. and 31 mm. respectively. between sizes 20 and 25.5. Sizes A set of LightSpeed instruments totals 26 and encompasses sizes 20 to 140. Barbakow / Dent Clin N Am 48 (2004) 113–135 Fig. the instruments are marketed in lengths of 21 mm.5. but also have white or black markings or engraved rings on the instrument’s handles. respectively. Overview of a LightSpeed instrument (left) with its short cutting head and thin noncutting taperless shaft compared with a K-FlexoFile (Dentsply-Maillefer.5. LightSpeed instruments also have half-sizes.

This design maximizes the flexibility of nickeltitanium and enables instruments to negotiate primary.5 is a transition instrument with a slightly longer noncutting pilot tip and a 33-degree cutting angle. the noncutting pilot tip is sectioned. taperless. respectively. whereas the radial lands and noncutting pilot tips help rotating LightSpeed instruments to remain better centered in canals (Fig. The first five LightSpeed instruments (sizes 20 through 30) have short.25 mm long. All other instruments (sizes 35 through 140) have longer and more slender noncutting pilot tips than do the transitional instrument and a 21-degree cutting angle. 1.F. 2). whereas in the other.25 mm and 2.5 mm from the root apex. Cutting heads of all LightSpeed instruments terminate in noncutting pilot tips (Fig. and 40 (left) and the radial lands and spiral grooves (original magnification 40).5 (right). SEM photomicrograph of three LightSpeed cutting heads showing differences between sizes 20 (top). In one canal. the smallest (size 20) and largest (size 140) LightSpeed cutting heads are 0. Fig. . noncutting pilot tips and a 75-degree cutting angle. The spiral grooves help to transport debris coronally. 2. In addition. 3). 4). LightSpeed is the only rotary system whose cutting heads have three different geometric shapes (Fig. 32. 5 illustrates a cross-section. noncutting shafts. Fig. Instrument size 32. The major differences between LightSpeed instruments and conventional stainless steel and nickel-titanium hand files are summarized in Table 1. Thin shafts LightSpeed is the only rotary system whose instruments have thin. the radial lands and spiral grooves are sectioned. Although cutting surfaces of most enginedriven instruments are 16 mm long. showing different parts of two cutting heads in two canals with different working lengths. and tertiary curves in both the bucco-lingual and mesio-distal planes. secondary. Barbakow / Dent Clin N Am 48 (2004) 113–135 115 grooves between the radial lands.

Junctions between shanks and colorcoded handles are 21 mm.005 mmc 20 140 Stainless steel Increases linearly 16 size Similar for all files Noa Yes Nob 0. The markings on the Fig. spiral grooves.16 to 0.116 F. In contrast.02 mm 08 140 Some files have a batt geometry. and 30 mm from the tip. and 31-mm long instruments. respectively. personal communication. For the 21-mm and 25-mm instruments. radial lands. Shanks and handles The thin. San Antonio. 28 mm. Switzerland) have intermediate sizes. 25-mm. the junction of the shaft and shank is 18 mm from the tip.51 mm 0. and part of the taperless shaft in an unusual perspective (original magnification 200).25 (140) Varies. taperless nickel-titanium shaft enlarges at one end to become the shank. 25 mm. DDS. indicating distances of 24 mm. the 31-mm instruments have four rings on the shank. July 2003. which in turn inserts into the aluminum handle. Barbakow / Dent Clin N Am 48 (2004) 113–135 Table 1 Differences between LightSpeed instruments and conventional stainless-steel endodontic files Metal/alloy Shaft diameter Length of cutting head (mm) Tip angles Noncutting pilot tip Tip design constant Intermediate sizes Tolerance Smallest size Largest size a b c LightSpeed instruments Conventional hand files Nickel-titanium 0. . and 31 mm from the tips for the 21-mm. 33. and for the 31-mm instrument. SEM photomicrograph of a LightSpeed cutting head showing the noncutting pilot tip. 26 mm. The shank is marked with rings that indicate distances from the instrument’s tip. which is 20 mm from the tip. Texas. and 24 mm from the tip. Although the 21-mm instruments have only one ring on the shank. and 75 degrees Yes No Yes 0. Steve Senia.25 (20) to 2. the distance is 22 mm. 3. 21. Ballaigues. 22 mm. the 25-mm instruments have three rings indicating distances of 20 mm. Golden Mediums (Dentsply Maillefer.

Working length is different in the two canals (original magnification 64. 5.F. Front and back of a LightSpeed cutting head showing dentin debris filling spaces between radial lands. 4. constant speed. constant torque. . Root apices of a maxillary first premolar with the LightSpeed MAR instruments fixed in situ and cross-sectioned 1. Foot pedals on dental units should be adjusted to maintain the constant speed. although cordless handpieces are recommended because of their low cost. shanks allow clinicians to select a wide variety of reference points without being limited to cuspal tips or incisal edges. Principles of the lightspeed technique Ideally. the constant rpm is important because nickel-titanium does not tolerate repeated changes in torque. scale ¼ 0. LightSpeed instruments operate optimally at high rpm in low-torque motors. and stopped only when the instrument is removed from the canal orifice. Instruments should already be rotating as they enter the canal.5 mm). Fig.5 mm from the tip showing the noncutting pilot tip and the cutting blades in the two canals. Barbakow / Dent Clin N Am 48 (2004) 113–135 117 Fig. LightSpeed instruments should rotate at a constant speed between 1500 and 2000 revolutions per minute (rpm) without exceeding 2000 rpm. and ease of use. continue rotating while cutting canal walls.

9]. and the third is the manufacturer’s recommended hybrid technique. Zurich LightSpeed technique Three special instruments should be singled out while using the Zurich LightSpeed technique. working lengths should first be reached with a loose-fitting. For the sake of completion. never skipping a size to gain time. preferably using the ‘‘Balanced Force’’ technique [2]. Two handpieces expedite instrument changeovers because although the clinician uses one handpiece. However. do not linger at that point and immediately withdraw the rotating instrument from the canal. using the latter when LightSpeed is working in the canal and as the final flush. thus maintaining the instruments’ cutting efficiency.118 F. and 25 Hedstro¨m files (Dentsply Maillefer. most importantly. if rubber stops are used. In very narrow canals it may be necessary to first reach the working length with size 08 or size 10 K-Files (Dentsply Maillefer). being able to modify the principles. adapting newer techniques to existing ones. Barbakow / Dent Clin N Am 48 (2004) 113–135 LightSpeed instruments require a straight-line access to the mid-root area. Switzerland). and clinicians frequently employ their own variations as well. A proven concept is to irrigate alternately with sodium hypochlorite and a liquid ethylenediaminetetraacetic acid. the chairside assistant can fit the next LightSpeed instrument into the second handpiece and set the length. The first is the Zurich LightSpeed technique [5–7]. size 15 hand file. Copious irrigation is important and it is advisable to maintain a reservoir of the irrigant in the pulp chamber. These are the ‘‘initial apical rotary’’ (IAR). the second is the manufacturer’s recommended LightSpeed technique [8. No further shaping can occur and lingering at a point only subjects the instrument to additional unnecessary metal fatigue. always use progressively larger instruments in the correct sequence from small to large. These changes indicate an increased confidence with the techniques. one way to gain time is to use two or more handpieces. This may require rasping coronal canal overhangs using size 15. With LightSpeed. 20. Irrigants help to remove debris that rapidly collects within the cutting flutes. Because the smallest LightSpeed instrument is a size 20. Consequently. cavity walls should be shaped so that they guide the rotating instruments unhindered to the mid-root area. Once a LightSpeed instrument has reached its desired length. Ballaigues. and. the . because the anatomy of root canals vary so widely. Publications have already described how different tapered rotary systems can be combined [10] and LightSpeed can readily be combined with other tapered systems. Details of the lightspeed technique Manufacturers of any rotary instruments modify their techniques from time to time. Such modifications or ‘‘evolutionary’’ changes have occurred with LightSpeed as well. three methods of using LightSpeed instruments are described.

Step 2: Determine working length and IAR After preflaring. one LightSpeed instrument will start to cut the canal walls at working length. The Zurich LightSpeed technique is divided into four steps. Nevertheless. The MAR may be 6 to 12 LightSpeed sizes larger than the IAR. The last instrument used to form . beginning with size 20. Step 1 constitutes the access and coronal preflaring. Nonbinding instruments advance in steps of 1 mm to 2 mm to the working length with slow. Eventually. These instruments also are used sequentially from smaller to larger sizes. their diameters are enlarged in a stepdown or crown-down procedure using Gates-Glidden burs (GGBs. the aim is to reach the working length. The first few LightSpeed instruments used may not ream the canal walls because the canals are too large. which begins to cut canal walls at the working length.12]. sequentially progressing to larger sizes without skipping a single size. Step 3: Determine MAR All LightSpeed instruments used after the IAR are called ‘‘binding instruments. Dentsply Maillefer). progressing from large to small sizes [11. each advancing with the ‘‘pecking’’ movements. and step 4 completes the step-back and recapitulation.F. Step 1: Access and coronal preflaring After the canal orifices are located. these instruments are termed ‘‘nonbinding’’ instruments. this is verified radiographically or electronically. three or four GGBs may be indicated. enlarging no more than the coronal 4 mm to 6 mm. always begin with size 20. The forward motion reams the canal. It is important to follow the root’s long axis and oval canals can be milled readily with the GGBs. The IAR is defined as the first LightSpeed instrument. controlled movements. in longer canals. In shorter canals. two GGBs may suffice. whereas the backward motion tends to clean the cutting head as it retreats into fresh irrigant.’’ They are used with controlled forward (1 mm to 2 mm) and backward (2 mm to 4 mm) ‘‘pecking’’ movements. this instrument is designated the IAR.5 mm into the canal. whereas the MAR is the last instrument to form the apical preparation. step 3 determines the MAR. The diameter of the apical preparation increases with each instrument that reaches working length. step 2 determines working length and the IAR. Each GGB advances only 1 mm to 1. The FR is the last step-back instrument and completes the stepback procedure. The step-down procedure or preflaring removes significant amounts of necrotic tissue and microorganisms from the canal coronally. LightSpeed instruments are used from this point on. the working lengths are determined for each canal using at least size 15 stainless steel K-Files. Barbakow / Dent Clin N Am 48 (2004) 113–135 119 ‘‘master apical rotary’’ (MAR). and the ‘‘final rotary’’ (FR) [7].

a broad apex calls for a larger MAR. The MAR should be reduced when the degree and angle of curvature are large or when the root apex on radiograph is thin and pointed. Table 2 Average sizes for MARs Tooth Maxillary teeth Centrals Laterals Cuspids 1st premolars 2nd premolars 1st molar buccals 1st molar palatal 2nd molar buccals 2nd molar palatal Mandibular teeth Centrals Laterals Cuspids 1st premolars 2nd premolars 1st molar mesial 1st molar distal 2nd molar mesial 2nd molar distal MAR size 70 60 60 60 50 40 50 40 50 60 60 80 60 50 40 50 40 50 . The last step-back instrument is termed the FR and runs into the step-down or coronal preflaring previously prepared. For this reason. and each subsequent step-back instrument is 1 mm shorter than the previous instrument. and amount of canal obliteration. the diameter of the final apical preparation also is controversial because it has been virtually ignored. the preparation’s final size must be larger than the canals preinstrumentation diameter. In contrast. To ensure that the apical preparation has cleaned the canal. The exact position of the apical preparation in relation to the radiographic apex depends on the clinician’s own philosophy and will vary from dentist to dentist.120 F. Barbakow / Dent Clin N Am 48 (2004) 113–135 the apical preparation is the MAR. Step 4: Step-back and recapitulation LightSpeed instruments are stepped-back after selecting the MAR. The working length for the first step-back instrument is 1 mm shorter than the canal’s working length. presence of secondary or tertiary curves in the canal. it has been called the ‘‘forgotten dimension’’ [9]. Likewise. The number of step-back instruments will vary from canal to canal. thinner or wider root apices. The MAR may be 6 to 12 LightSpeed instruments larger than the IAR. The size of the MAR can be modified and depends on several factors such as the degree and angle of curvature. A review of the literature suggests the average sizes for MARs (Table 2) [9].

(A) Working length radiograph of a mandibular second molar scheduled for LightSpeed preparation using the ‘‘Zurich technique’’ (February 11. 1997). A. This procedure calls for .06 tapered system to be used according to the manufacturer’s instructions. Barbakow / Dent Clin N Am 48 (2004) 113–135 121 Finally. all canals are recapitulated once with using their respective MARs to working length. MAR in all canals was size 50. Bensheim. Figs. Note the apical periodontitis on the mesial and distal root apices (case supplied by Dr. Germany) restoration and healed apical areas (January 28. (B) Final fill radiograph (lateral condensation) of the mandibular second molar (Fig. Bindl). 6 through 9 detail four molars that were endodontically treated by general practitioners using the Zurich LightSpeed technique.04 or . From this Fig. A.F. A. Both apical radiolucencies are resolving (case supplied by Dr. but only until the size 20 instrument completes the crown-down mode. 2002. . 6. Bindl). 1997). Bindl). 6A) prepared with LightSpeed instruments (May 27. The Zurich LightSpeed technique can be combined readily with currently marketed tapered rotary systems. 6A with a Cerec (Sirona. case supplied by Dr. (C) Thirty-month follow-up radiograph of the mandibular second molar shown in Fig.

a straightline access should be made. Manufacturers recommended LightSpeed technique The manufacturers recommended technique states that before beginning instrumentation with LightSpeed. and which LightSpeed instrument begins the instrumentation. advancing apically using moderate pressure but never rotated. Step 1: Determine the LightSpeed size that is used to begin rotary instrumentation (sizing or gauging the apical canal diameter) This step determines the smallest canal dimension from the canal orifice to the working length. the working length should be determined. Pulp tissue should be removed with broaches when possible and then LightSpeed instruments are used to complete canal preparation in the five steps described below. the apical and middle thirds of the canal (5 mm to 8 mm) are completed using LightSpeed instruments as described above.122 F. Continuing with . Barbakow / Dent Clin N Am 48 (2004) 113–135 Fig. The concept of gauging or sizing is as follows. The sizing process (gauging) avoids wasting time using LightSpeed instruments that are too small for the canal and provides valuable information about preinstrumentation canal size—information that is critical to prevent the underpreparation of canals. Gauging continues with sequentially larger sizes until a LightSpeed instrument does not go to working length. 6 (continued ) point. and canal patency should be achieved with at least a size 15 K-type file [13]. a size 25 LightSpeed that goes to working length indicates that the canal’s diameter is larger than the size 25 instrument. A LightSpeed instrument can reach working length if its cutting head is smaller than the canal’s diameter from orifice to working length. To gauge (size) with LightSpeed instruments correctly they must be used by hand. the canal should be flared coronally with any instrument such as GGBS (not LightSpeed). For example.

and then progress apically with an advance and withdrawal motion (‘‘pecking’’). immediately stop advancing.5 does not. Step 2: Determine the apical preparation size Start instrumenting with the FLSB using a slow. This ‘‘pecking’’ movement translates into a downward cut of the dentin followed .5 (case supplied by Dr. A. MAR in the four canals was size 47.5 (case supplied by Dr. 1996). continuous movement. (A) Radiograph of the final fill (lateral condensation) of four canals in a maxillary first molar prepared with LightSpeed instruments using the ‘‘Zurich technique’’ (December 12. advancing cautiously until it engages the canal walls.F. then size 27. Barbakow / Dent Clin N Am 48 (2004) 113–135 123 Fig. 2003). 7. Bindl). The FLSB is placed in the handpiece to begin rotary instrumentation. MAR in all four canals was size 47. pause for a fraction of a second. Bindl). if size 25 reaches working length but size 27. (B) Five-year follow-up radiograph of the maxillary first molar shown in Fig. A.5 is called the First LightSpeed Size to Bind (FLSB). the above example. At this point. 7A (February 24.

respectively. Count the number of pecks it takes the FLSB to reach working length. the cutting head works harder because it is removing more dentin. As the canal is cut rounder. (B) Eighteen-month follow-up radiograph of the mandibular second molar shown in Fig. 8A (April 1996) obturated with ThermaFil. The instrument that takes at least 12 pecks to reach working length is the . Zafran). After determining the FLSB. Zafran). MAR in the two mesial canals and one distal canal were sizes 42. (A) Working length radiograph of a mandibular second molar scheduled for preparation with LightSpeed instruments using the ‘‘Zurich technique’’ (November 1994). repeating the counting of pecks with each sequentially larger instrument.5 and 50. Barbakow / Dent Clin N Am 48 (2004) 113–135 Fig. the appropriate size of the apical preparation to achieve the significant goal of apical cleaning is determined. J. J. by a slight withdrawal of about 1 to 3 mm. 8. Note the healed endo-perio lesion adjacent to the distal root (case supplied by Dr. Note the endo-perio lesion adjacent to the distal root (case supplied by Dr. The extra cutting effort requires more pecks to advance the instrument from when it starts cutting until it reaches working length.124 F.

or smaller-sized MARs. 9A (February 1996. case supplied by Dr. which varies from tooth to tooth. J. There is no such thing as a given canal size for each tooth in the mouth. respectively (case supplied by Dr. This enables the 5-mm long SimpliFill GP .F. This is called the 12 ‘‘pecks’’ rule. Zafran). respectively. MAR in the two mesial canals and one distal canal were sizes 42. Step 3: Complete apical instrumentation After determining the MAR size with the 12 ‘‘pecks’’ rule. complete the apical preparation by using the very next LightSpeed size that is 4 mm shorter than the working length. Barbakow / Dent Clin N Am 48 (2004) 113–135 125 Fig. MAR. The size of the MAR depends on the preinstrumentation canal size. Zafran). Canals with naturally large or small sizes will have larger. J. 9.5 and 50. (B) Fifteen-month follow-up radiograph of the mandibular second molar shown in Fig. (A) Final fill radiograph (ThermaFil) of a mandibular second molar prepared with LightSpeed instruments using the ‘‘Zurich technique’’ (November 1994).

Step 5: Recapitulate Recapitulate to the working length of each canal with the respective MAR. Do not allow any mid-root instrument to enter the apical 5 mm.126 F.04 or . LightSpeed technique combined with taper technique LightSpeed Endodontics recommends this hybrid technique for clinicians wishing to combine both tapered rotary and LightSpeed systems. The MAR is the instrument that required at least 12 ‘‘pecks’’ to reach working length (step 2). if obturating with standardized GP cones. With the combined technique. For example. continue instrumenting the middle 4 to 5 mm of the canal only with sequentially larger full size (skip half-sizes) LightSpeed instruments. step back 4 mm with sequentially larger LightSpeed instruments so that each length is 1 mm shorter than the previous instrument. Use the same ‘‘pecking’’ motion described in step 2 until a LightSpeed instrument no longer advances easily. step back in 1-mm increments to at least a size 65. However. After entering the canal. canals can be cleaned and shaped in a crown-down fashion according to the technique recommended by the manufacturer of the tapered instruments used. Continue this process with sequentially larger LightSpeed full sizes until reaching a size that cannot advance easily past the apical extent of the coronal third of the canal. The hybrid technique assumes that the canal has first been instrumented to working length with . Then. without rotating it and using moderate force. LightSpeed instruments are used to complete the apical preparation. if obturating with standardized GP cones. if the MAR is a size 40. This prepares the apical 5 mm of the canal with a taper matching that of a standardized cone. LightSpeed instruments complete the apical part of the canal [8]. After the crown-down is completed. always start the gauging process by hand with a size 35 LightSpeed instrument. Step 1: Apical gauging Follow the concept of apical gauging described in step 2 of the manufacturers recommended LightSpeed technique. Barbakow / Dent Clin N Am 48 (2004) 113–135 Plug (LightSpeed Endodontics) to closely match the size and shape of the canal preparation. advance the instrument apically and one of three things will occur: . do not skip half-sizes during the mid-root preparation. In this way. Continue the step-back from working length in 1-mm increments until reaching a LightSpeed size that is at least 25 larger than the MAR. However. Step 4: Instrument mid-root If obturating with SimpliFill.06 tapered rotary instruments with a tip size 25 using the manufacturer’s recommended technique.

Reconfirm that the tapered preparation was performed correctly. even when canals were . others modify the methods that they have learned at courses on LightSpeed or other nickel-titanium rotary techniques. Step 2: Begin LightSpeed rotary preparation Place the FLSB determined in steps 1A or 1B in the handpiece and begin instrumentation using the same hand motions and following the exact technique described in step 2 of the manufacturers recommended LightSpeed technique. apical preparations in mesial canals of mandibular molars produced little or no apical transportation when prepared by LightSpeed instruments [14]. If the size 35 LightSpeed instrument binds more than 3 mm short of the working length. Independent studies performed since 1995 [14–21] indicate that LightSpeed instruments produce better-centered apical preparations compared with other files or instruments. Although using two rotary techniques has advantages. Nevertheless. then file the canal with K-files until a size 35 LightSpeed instrument reaches working length. Discussion This article discusses three ways to use LightSpeed instruments. If confirmed to be correct and the size 35 gauging instrument still does not bind within 3 mm of working length. particularly for the larger sizes. If the size 35 instrument reaches working length without binding. the three techniques are described to give experienced and nonexperienced users pointers on how LightSpeed instruments may be used. some clinicians complain about combining two systems and the related increased costs. if the size 35 instrument does not reach working length but binds 3 mm (or less) short of the working length. this instrument is called the FLSB). Consequently. two of the three techniques in this article describe using LightSpeed instruments alone and one describes the combined use of LightSpeed with tapered rotary instruments. LightSpeed instruments enable larger apical preparations because their design maximizes the flexibility of nickel-titanium more so than do other rotary instruments currently available. Generally. then it also is called the FLSB. continue gauging with sequentially larger LightSpeed instruments until one binds before the working length (as explained previously. Proceed to step 2. Although some clinicians may do just that. Proceed to step 2. The apical preparation is complete when the canal is instrumented to the MAR using the 12 ‘‘pecks’’ rule. Barbakow / Dent Clin N Am 48 (2004) 113–135 127 A. However. For example. B. Then proceed to step 2. Purists may contend that the manufacturer’s recommended technique always should be followed to the letter. C. it means that the apical part of the canal is not ready to be mechanically prepared with LightSpeed instruments.F.

coronal thirds are not overinstrumented because of the unique design of LightSpeed instruments. personal communication. July 2003). disruption. The instruments then can be sorted. microcomputer tomography [22] showed that up to 40% of root canal walls remained uninstrumented when shaped by different rotary techniques or manually [23]. LightSpeed instruments should be ultrasonicated in tap water for a few minutes in small portable devices to remove any biologic material lodged within the cutting flutes. the manufacturer recommends using the smaller LightSpeed sizes (20–47. metal strips. minor imperfections also were found on new instruments . Barbakow / Dent Clin N Am 48 (2004) 113–135 prepared using size 50 LightSpeed instruments [17]. Consequently. an apical preparation larger than the uninstrumented canal size must be the aim of any root canal preparation. Nevertheless.5) for up to 8 cases and the larger sizes (50 and above) for up to 16 cases. LightSpeed instruments are too expensive to be used only once. To summarize. Wear of LightSpeed cutting heads includes microfractures. 11). placed in the special LightSpeed Organizer (LightSpeed Endodontics). Texas. They suggest that each tooth with normal canal curvatures. 10. However. including molars. Detailed anatomy of apical constrictions [29] and mean diameters of root canals near the apical foramina [30–33] suggest that larger preparations are necessary to optimize the cleaning procedure. Although apical preparations can be made to larger sizes. and pitting or fretting (Figs. DDS. 95% of molar mesial canals require shaping to at least a size 60 to adequately instrument the apical 1 mm [32]. if the chemomechanical removal of microorganisms is the goal in endodontics. After usage. On the other hand. Instrument maintenance and replacement Concepts must be in place so that chairside assistants know how frequently rotary instruments have been used clinically. despite an electronic scan of the literature. and sterilized in the usual manner. then it is logical to conclude that larger apical preparations may yield better outcomes. be considered a case (Steve Senia. The logical question is ‘‘are larger apical preparations necessary’’? Recent studies [24–27] indicate that larger apical preparations removed more infected tissue and bacteria. but cyclic and torsional fatigue may cause instruments to fracture if they are used too frequently. no publications were found linking better clinical outcomes to larger-sized apical preparations. San Antonio. it is well established that bacteria in root canals are endodontists’ main problems and if larger apical preparations reduce bacterial counts. Furthermore.128 F. Instruments should be replaced after a single use when the degrees of curvature are excessive or abrupt (short radius) curvatures are present. To highlight this point. larger apical preparations create more space for larger amounts of irrigants to ensure a more effective disinfection [28].

Barbakow F.) . Barbakow F. Int Endod J 1998.F. Lutz F.31(1):60.) Fig. Lutz F. Photomicrograph (original magnification 215) showing metal strip on the noncutting pilot tip of a size 37. Scanning electron microscope appearance of Lightspeed instruments used clinically: a pilot study.5 LightSpeed instrument used clinically in 20 canals. with permission. with permission. Barbakow / Dent Clin N Am 48 (2004) 113–135 129 Fig. (Modified from Marending M.31(1):60. Int Endod J 1998. Scanning electron microscope appearance of Lightspeed instruments used clinically: a pilot study. Photomicrograph (original magnification 90) of a disrupted edge and metal flash of radial lands of a size 50 LightSpeed instrument used clinically in 20 canals. (Modified from Marending M. 11. 10.

Minor imperfections in unused LightSpeed instruments show how difficult it is to machine such delicate nickel-titanium instruments. It would be interesting to compare the wear of LightSpeed instruments to the wear of other nickel-titanium rotary instruments. By so doing. Explain any mishap to the patient. particularly for the larger sizes.130 F. Instrument fracture is a real concern for clinicians. One is at the shaft–shank junction and is due to excessive angulation of the instrument in the canal orifice combined with poor access or unintended tipping of the handpiece by the clinician (Fig. LightSpeed instruments are not prone to fracture but when they do. and maximize the flexibility of nickel-titanium. more disinfecting irrigants can reach the apical areas and may ensure a better disinfection. Such fractured instruments are removed readily from the root canals. which accelerates metal fatigue. Consequently. are unique in their design. particularly in curved canals when the manufacturer’s basic guidelines are ignored. the LightSpeed methods should be mastered before using them on patients. Barbakow / Dent Clin N Am 48 (2004) 113–135 [34.35]. informing him or her of the pros and cons involved in any subsequent therapy. but practicing the technique diligently and being aware of the important do’s and don’ts pertinent to the LightSpeed technique can significantly reduce the incidence of fracture. or left in situ and integrated in the oburation. B). . They may be bypassed. LightSpeed instruments are fascinating. Summary LightSpeed instruments. and long thin taperless shafts. The instruments maximize the flexibility of nickel-titanium. beginning with simpler canals and then progressing to more challenging cases. The second site for fracture is a few millimeters from the cutting head and generally is caused by excessive feed (locking the cutting head in the canal) or excessive speed. innovative. they enable larger apical preparations without overpreparing the coronal canal thirds. fractures may occur at two sites. 13A–C). Also tell the patient how important regular follow-ups are to determine the treatment’s outcome. noncutting pilot tips. Such fractured segments are more difficult to remove (Fig. Box 1 summarizes the more important do’s and don’ts pertinent to the innovative LightSpeed technique. Instrument fracture Any rotary instrument can fracture. better mechanical removal of necrotic debris and microorganisms may be possible. When used properly. with their short cutting heads. Just as with any new technique. With larger canal spaces. The latter is indicated when larger instruments are involved and the greater part of the canal has been cleaned and well irrigated. 12A.

Barbakow / Dent Clin N Am 48 (2004) 113–135 131 Fig. 12.F. N. (A) Radiograph showing a fracture in the ‘‘shaft-shank area’’ of a LightSpeed instrument in the disto-buccal canal of a maxillary first molar (case supplied by Dr. . N. Gabutti). 12A following removal of the fractured LightSpeed segment from the disto-buccal canal (case supplied by Dr. Gabutti). (B) Final fill radiograph of the tooth shown in Fig.

132 F. Barbakow / Dent Clin N Am 48 (2004) 113–135 .

Ensure that the instrument continuously rotates while in the canals 8. Barbakow / Dent Clin N Am 48 (2004) 113–135 133 Box 1. 13A (case supplied by Dr. A final word of thanks goes to Syngcuk Kim and b Fig. Beatrice Sener. 13. and Anna-Lise Teuscher for preparing the photographic material.F. Never skip an instrument size to try and gain time 9. Use a light touch at all times for all sizes 2. P. Velvart). (A) Radiograph showing a fractured LightSpeed instrument in a mesial canal of a mandibular second molar (case supplied by Dr. Velvart). Summary of do’s and don’ts when using LightSpeed instruments Do’s 1. P. . (B) View of the fractured surface of a LightSpeed shaft seen through an operating microscope and the retrieved instrument after removal using ultrasonics (case supplied by Dr. Reduce the feed distance when resistance is felt 6. Don’t vary the speed while instruments are rotating in the canal 6. (C) Radiograph confirming retrieval of the fractured LightSpeed segment shown in Fig. Velvart). Maintain a constant speed 7. Don’t linger at a point when the working length has been reached 5. Peter Velvart. P. Don’t force LightSpeed instruments 2. Don’t use LightSpeed without rubber dam 7. Replace instruments at regular intervals Don’ts 1. Don’t overuse LightSpeed instruments Acknowledgments The author thanks many people who helped compile this manuscript including Andi Bindl. Nick Gabutti. Don’t exceed a speed of 2000 rpm 4. Always irrigate canals before using LightSpeed instruments 3. Control the forward and backward motions when carrying out the ‘‘pecking’’ 5. 13A (case supplied by Dr. Don’t use LightSpeed instruments in dry canals 3. and Jakob Zafran for allowing the author to present their LightSpeed cases and Liselotte Brandenberger. (D) Final fill radiograph after retrieving the fractured segment shown in Fig. Maintain a reservoir of irrigant in the pulp chamber 4. Always concentrate when using LightSpeed instruments 10. P. Velvart).

J Endod 1998. Ni-Ti engine-driven and K-Flex endodontic files. [6] Eggert C. Dove SB.35(1):37–46. [2] Roane JB. com/techniqueguide. 7(1):31–40. Int Endod J 1998. Bakland LK. [13] Senia ES.31(2):103–11. [12] Morgan LF.21(3): 146–51. Endodontic cavity preparation. [19] Shadid DB.10(10):491–8. Senia ES. Haller RH. Lutz F.23(8):503–7. Preparation of the apical part of the root canal by the LightSpeed and step-back techniques. Endod Prac 2000. Morgan LA. Scha¨fers F. Endod Prac 2000. Martin D. Bakland LK. [Preparing curved root canals using the Lightspeed method. Duncanson MG. J Endod 1985. LightSpeed technique guide. Available at: http:// www.6(4):267–72. Available at: http://www. Teil 1. Barbakow F. p. Nicholls JI. All these names prove yet again that ‘‘no man is an island to himself. J Endod 1982. [Preparing curved root canals using the Lightspeed method. [7] Peters O. J Endod 1988. Ibarrola JL. [16] Short JA. Int Endod J 1996. A comparative study of root canal preparation using Profile.29(2): 113–7. Accessed July 28. Peters O. Baumgartner JC. [4] Wildey WL. instrumentation. A comparison of curved canal transportation with balanced force versus lightspeed. 92–227. Brantley WA. Mullaney TP. Michelich RJ. 3(2):28–33. In: Ingle JI. Barbakow / Dent Clin N Am 48 (2004) 113–135 John Vassallo for their patience and understanding. Peters O.’’ References [1] Ingle JI. [14] Glossen CR. [Root canal preparation using Lightspeed instruments hands-on manual. Baltimore: Williams & Wilkins. A comparison of root canal preparations using Ni-Ti hand.134 F. Sabala CL.com. Schultz HH.8(12):550–4. Barbakow F. Hu¨lsmann M. 1997. del Rio CE. [9] Senia ES. Endodontie 1997.11(5):203–11. [10] Machtou P. Straightline access guide.] Grundlagen. Comparing apical preparations of root canals shaped with nickel-titanium rotary and nickel-titanium hand instruments. Int Endod J 2002. Lutz F. Aufbereitung gekru¨mmter Wurzelkana¨le unter Anwendung der Lightspeed-Methode. Barbakow F. Gerstein H. Assessing apical deformation and transportation following the use of LightSpeed root-canal instruments. [20] Versu¨mer J. J Endod 1997. [17] Portenier I. Barbakow F. [11] Goerig AC.24(10):651–4. Part 2: practical procedure. J Endod 1984. Praktische Anwendung. Klinische Anwendung manual.14(7):346–51. The ‘‘balanced force’’ concept for instrumentation of curved canals. 4th edition. Aufbereitung gekru¨mmter Wurzelkana¨le unter Anwendung der Lightspeed-Methode.lightspeedusa.3(2):34–9. J Endod 1995. 14–38. Wildey WL. Eggert C. Peters DL. [15] Knowles KI. [18] Deplazes P. Instrumentation of root canals in molars using the step-down technique. Barbakow F. An initial investigation of the bending and torsional properties of nitinol root canal files. Christiansen RK.27(3): 196–202.] Zurich: Verlag PPK.LightSpeed. editors. 2003. Canal diameter: the forgotten dimension. . Part 1: basic principles.04 and LightSpeed rotary Ni-Ti instruments.67(2): 198–207. Eggert C. Accessed July 28. [5] Peters O. Steiner JC. Montgomery S. Buchanan LS. p. 2003. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1989. [8] Senia ES. 1994.] Endodontie 1998.html. Endodontics. Teil 2. Advances in rotary instrumentation sequences. A new root canal instrument and instrumentation technique: a preliminary report. J Endod 2001. A comparison of canal centering ability of four instrumentation techniques. Wurzelkanalpra¨paration mit LightspeedInstrumenten. Wildey W. Meyer E. An evaluation of the crown-down pressureless technique. [3] Walia HM.

17(4):192–8. [30] Kerekes K. Tronstadt L. Barbakow F. The position and topography of the apical canal constriction and apical foramen. Tronstadt L. [34] Marending M. J Endod 2002.F. Effects of four Ni-Ti preparation techniques on root canal geometry assessed by micro computed tomography. J Endod 1977. Scanning electron microscope appearance of LightSpeed instruments used clinically: a pilot study. [31] Kerekes K.26(12): 751–5. Efficacy of bacterial removal from instrumented root canals in vitro related to instrumentation technique and size. J Endod 1977. . Barbakow / Dent Clin N Am 48 (2004) 113–135 135 [21] Weiger R. Preparation of curved root canals with rotary FlexMaster instruments compared to LightSpeed instruments and NiTi hand files. Bru¨ckner M. Scho¨nenberger K. [24] Shuping GB.79(6):1405–9. [27] Rollison S. [25] Card SJ.28(11):779–83. Int Endod J 1984. Laib A. [22] Peters OA. ElAyouti A. Effects of irrigation on debris and smear layer on canal walls prepared by two rotary techniques: a scanning electron microscopic study. Ru¨egsegger P.28(3):181–4. Santos SR. [28] Peters OA. J Endod 1999. Rees DG. Stevens RH. J Endod 1977. Barbakow F. J Endod 2000.25(7):494–7. Morphometric observations on the root canals of human molars. Tronstadt L. J Endod 1999.31(1):57–62.3(1):24–9. Sigurdsson A. J Endod 2000. Magalhaes FAC. Morphometric observations on root canals of human anterior teeth. Int Endod J 2001. Int Endod J 2002.25(10):689–91. Efficacy of instrumentation techniques and irrigation regimens in reducing the bacterial population within root canals. [33] Gani O. 26(1):6–10. Rocas IN.3(2):74–9. Sigurdsson A. Int Endod J 1998. Morphometric observations on root canals of human premolars. The effectiveness of increased apical enlargement in reducing intracanal bacteria. Apical canal diameter in the first upper molar at various ages. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002. J Endod 2002. Orstavik D. Orstavik D. McGinn JH. [35] Eggert C. Three dimensional analysis of root canal geometry using high resolution computed tomography. Visvisian C. Wear of nickel-titanium LightSpeed instruments evaluated by scanning electron microscope. Reduction of intracanal bacteria using nickel-titanium rotary instrumentation and various medications. J Dent Res 2000. Lima KC.94(3):366–71. Laib A. Trope M.34(3):221–30.36(7):483–90. Lutz F. Barbakow F.3(3):114–8. Trope M. [32] Kerekes K. [23] Peters OA. Barnett F. Lo¨st C. [26] Siquiera JF. Barbakow F. Peters O. [29] Dummer PMH. de Uzeda M.

cden. 25-. Orange. K3 canal shaping files with a fixed taper of 0. California) was introduced initially in North America in January 2002 (Fig.Dent Clin N Am 48 (2004) 137–157 The K3 rotary nickel–titanium file system Richard E. Georgia). All rights reserved. The K3 has universal applicability across a wide range of clinical indications and includes the following features: 1. doi:10. A series of three radial lands with a relief behind two of the three lands (Fig. The proportion of the core diameter to the outside diameter is greatest at the tip where strength is most needed. DDS Private Practice. Asymmetrically placed radial lands and unequal land widths. U-shaped rotary instruments possess a negative rake angle. resulting in greater flute depth and increased flexibility while maintaining strength. and 30mm lengths. E-mail address: Lineker@aol. flute widths. 0.1016/j. This feature enhances flexibility over the entire cutting length. 4. No.04. 5). 2. This feature reduces friction on the canal wall. A slightly positive ‘‘rake’’ angle (Fig.11. OR 97205.com 0011-8532/04/$ . the 0.2003. The K3 system was designed by Dr. 7). 511 Southwest 10th Avenue. 4).06. USA The K3 rotary nickel–titanium file system (SybronEndo. 1). An ‘‘Axxess’’ handle design. A variable core diameter (Fig. 6. Portland.002 . 5.02.see front matter Ó 2004 Elsevier Inc.04 and 0. John McSpadden (Lookout Mountain. or 0. 3). (The 0. virtually eliminate transportation. and flute depths (Fig. which shortens the file handle by approximately 5 mm without affecting the working length of the file (Fig. 6). and 30-mm lengths) (Fig. 2). The proportion then decreases uniformly as the fluting moves up the taper. 25-. and add peripheral strength.06 tapered K3 files are available in tip sizes 15 to 60 and in 21-. 3. Asymmetrical flutes allow the K3 to provide superior canal tracking.02 tapered K3 files are available in tip sizes 15 to 45 and in 21-. A positive rake (cutting) angle provides a more effective cutting surface than a negative one. aid in preventing the file from screwing into the canal. 1108. Mounce.

The K3 rotary nickel–titanium file system (SybronEndo. 9. 9). Mounce / Dent Clin N Am 48 (2004) 137–157 Fig. and 0. Orange. 2. This feature also helps prevent the screwing-in effect common with some brands of files and promotes debris removal. 8. 1.E.08. 7. The availability of K3 canal shaping files with regard to taper. California) was introduced initially in North America in January 2002. K3 ‘‘body shaper’’ files with an enhanced taper of 0. 10. and ‘‘deep body’’ Fig. orifice openers.10. Color coding to distinguish between different tip sizes and tapers (Fig.12 that can act as both canal shaping files. 0.138 R. tip size. and length. 8). . A variable flute pitch (Fig. 10). A safe-ended cutting tip (Fig.

11). The K3 has a positive rake angle. The fluting on the straight (nontapered) shank is not designed to cut effectively and the straight Fig.06 tapered K3 files. 0. 3. which increases flexibility over the entire cutting length.R.E. providing a more effective cutting edge (SybronEndo). which provides the cutting function to the file). shaping files (these are available in a fixed tip size of 25 and in 17-.02. allowing for a smaller maximum diameter at the shank and creating a more flexible instrument. These body shapers have a modified design relative to the 0. and 25-mm lengths) (Fig. The K3 has a variable core diameter. 21-. . and 0.04. The body shapers have a shorter taper length (the apical 8 mm. 4. Mounce / Dent Clin N Am 48 (2004) 137–157 139 Fig.

(A–C) In cross-section. The feature reduces friction on the canal wall and prevents the file from overengagement. Generally. less cutting time. these files are rotated at 350 rpm. and decreased fracture rates. the K3 body shapers channel debris away from their tips.140 R. Mounce / Dent Clin N Am 48 (2004) 137–157 Fig. the K3 has a series of three wide radial lands to keep the file centered. The K3 body shapers have a slightly different helix angle relative to the other K3 sizes and tapers to make them cut more smoothly. with a relief behind two of the lands.E. . 5. The remaining flutes are parallel so as to increase file flexibility and optimize the rate at which the file can be introduced into the canal. shank section does not have relieved radial lands. the tapered region of the body shapers’ flutes are relieved at the distal of their radial lands to reduce peripheral surface contact. By design. enhancing performance. which can mean somewhat less required recapitulation. Like the original K3 files.

. The K3 (right panel) has asymmetrically placed radial lands of unequal width and unequal flute widths and depths that aid in preventing the file from ‘‘screwing into’’ the canal. 6. The K3 negotiates canals with ease and without undue force.’’ increasing the risk of separation. The K3 has excellent fracture resistance. the K3 moves smoothly down the canal with a robust sense of tactile control. the K3 feels stable and solid. especially those of variable taper (Fig. 5 (continued ) The author’s experience with the K3 In the author’s hands. U-shaped files (left panel) have symmetrical attributes that promote ‘‘screwing in. In contrast. Fig.R. In essence. 12).E. It does not feel as though the file will fracture at any moment. Mounce / Dent Clin N Am 48 (2004) 137–157 141 Fig. far better than other commercially available brands.

. yet does not pull itself into the canal apically. Their tactile sense of rigidity or ‘‘stiffness’’ in hand has no clinical correlation. The K3 can be used more than once in all tapers.02 and Fig. especially above a tip size of 25. The 17-mm body shapers have the greatest universal applicability. Mounce / Dent Clin N Am 48 (2004) 137–157 Fig. which shortens the file handle by approximately 5 mm without affecting the working length of the file. 7. This ability to bend is a unique feature not possessed by other commercially available brands. The 0.E. The 25-mm K3 canal shaping instruments are easier to visualize under the surgical operating microscope due to the Axxess handle. The K3 has a variable flute pitch to reduce the ‘‘screwing in’’ effect common with some brands of rotary nickel titanium files. It also has excellent cutting ability.142 R. The K3 will bend out of straight alignment when used beyond its elastic limit and should be discarded with this occurrence and with the presence of wear marks. The file cuts dentin effectively. 8. The K3 instruments are more than adequately flexible. The 25-mm K3 files are easy to use and visualize even with patients of limited opening and access. How many times a file can be used before it is discarded is a matter of clinical judgment (see the later section on ‘‘Assumptions for K3 clinical technique’’). An ‘‘Axxess’’ handle design.

Tulsa. Because the K3 tracks the canal easily.04 tapered K3 files in the smallest tip sizes (15–20) make excellent tracking files as an aid to helping create and/or accentuate a glide path. concluded that in extracted teeth.’’ In addition. 9. using microfocus CT. A safe-ended cutting tip. Bergmans and colleagues [1].’’ There was no significant difference in transportation between the two groups and with regard to their tendency to straighten the canal.R.E. the ProTaper (Dentsply Tulsa Dental. Fig. 0. Literature Because of the relatively recent introduction of the K3 into the marketplace and despite its widespread popularity. The K3 has simple color-coding to distinguish between different tip sizes and tapers. the 0. after a glide path has been established to a size 10 K file. 10. Oklahoma) and the K3 ‘‘were capable of preparing canals with optimum morphological characteristics in curved canals.02 and 0. it moves smoothly down the root to accentuate the initial shapes created by hand in the preparation of the glide path. Mounce / Dent Clin N Am 48 (2004) 137–157 143 Fig.04 size 15 file will generally slide close to true working length and create efficiencies with regard to insertion of subsequent files. Specifically. there is limited literature available. for example. . ‘‘the amount of dentin removal at all separate horizontal regions was comparable for both groups.

12 that can act as both canal shaping files. orifice openers. This study’s findings with regard to file fracture do not match clinical reality as experienced by the author. In the author’s personal experience . 11 K3 instruments fractured. 0. K3 ‘‘body shaper’’ files with enhanced taper of 0. Shafer and Florek [2] compared K3 to stainless steel K-Flexofiles in simulated canals with 28 and 35 curves in resin blocks with a rotational speed of 250 rpm with a crown down technique to a size 35 at the endpoint of preparation. During the preparation of 96 canals. and 25-mm lengths (SybronEndo).08.10.and postinstrumentation images were recorded and an assessment with regard to material removal was measured at 20 points beginning 1 mm from the apex. Pre. 21-. and deep body shaping files (these are available in a fixed tip size of 25 and in 17-. The authors concluded that the K3 instruments achieved better canal geometry and showed significantly less canal transportation than the hand-powered K-Flexofiles.144 R.E. Mounce / Dent Clin N Am 48 (2004) 137–157 Fig. 11. 0.

Do not force . rotating the files at 250 rpm may also have contributed to this finding instead of at the recommended 350 rpm. It is possible that the performance characteristics of the K3 in resin bear no resemblance to those in human teeth and that the master apical rotary size used in the study (size 35) is larger than that most commonly employed in clinical practice. Never put more force on a K3 file than you would use on a soft lead pencil. when employed with the K3. B) The K3 has excellent fracture resistance. is difficult to fracture and will do so only if used after it has acquired deformations (an indication for being discarded) or a significant amount of undue force is placed on it. Assumptions for K3 clinical technique Use of the K3 embraces the following concepts for enhanced cleansing and shaping and prevention of file separation. the K3. 12. (A. Mounce / Dent Clin N Am 48 (2004) 137–157 145 Fig. with the K3 in daily clinical practice.R. for the most part.E. Also. Removal of separated rotary nickel– titanium files is an ultrasonic microscopic procedure as illustrated. the operator can be assured of optimal K3 performance and more predictable long-term clinical results. Although many of these assumptions are also applicable to other rotary file systems.  Be gentle and deliberate in your motions with the K3.

Crown down instrumentation is desirable. The longer the irrigant is in contact with the canal. Patency refers to the deliberate attempt to keep the minor constriction of the apical foramen open during instrumentation procedures so as to block the apex with dentin mud. especially in the apical third.146     R. and blockage can be a major factor in causing iatrogenic events (most commonly ledging and separated instruments). smooth. Pull back at the first sign of undue resistance in the canal. and deliberate and in approximately 1to 2-mm deeper increments relative to the last instrument.25% sodium hypochlorite is desirable. Failure to do so (instrumenting dry) can create a plug of apical dentin mud and increase the risk of transportation or instrument fracture. In some calcified and curved roots. it may be necessary to irrigate and recapitulate after every K3 insertion to keep the foramen open (Fig. often with iatrogenic results. the middle third second.E. Mounce / Dent Clin N Am 48 (2004) 137–157 a K3 apically that resists movement. Using the K3 from larger to smaller tips sizes (of the same or varying taper) incorporates crown down instrumentation as each successively smaller file progresses further down the canal passively. Failure to do so can create a collagenous mass of pulp that can be pumped irretrievably into the narrowing cross-sectional diameters of the root canal system. 14). Patency is most often obtained by using small K file sizes of 6 to 15 after every rotary file just slightly (usually 1 mm) out the apical foramen to make sure that the canal path is clear to its most apical extent. SmearClear includes surfactants that reduce surface tension and allow maximum wetting of the canal walls for greatest efficacy (Fig. Dentin mud includes pulp and dentin debris from instrumentation that can plug the apical foramen and prevent negotiation to the constriction mentioned previously. 15). 13). move the canal from its original position. Patency is maintained. and apical third last (Fig. . the more effective its tissue dissolving capability. An average molar tooth might optimally require 72 to 144 cc of irrigant delivered with a close-ended. Frequent irrigation with 5. SybronEndo) after a final sodium hypochlorite irrigation is optimal. gentle. EDTA should be used from the start in all vital cases and can emulsify and hold the pulp in suspension until its removal by way of irrigation. K3 files and the body shapers can be taken to the true working length and used as the master apical file. EDTA or sodium hypochlorite (or both) should be in the canal or canals at all times. The motion in entering the K3 into the canal should be slow. Rinsing or soaking the canal with liquid EDTA (SmearClear. Crown down instrumentation implies that the coronal third is instrumented first. or change the foramen’s original size and shape. Patency is important primarily because its loss causes significant debris to remain harbored in the canal’s apical third (predisposing the case to failure). Removal of the smear layer present after instrumentation is desirable. side-venting needle.

Employ an instrument that is smaller or larger at the point of resistance (to either create more shape above the resistance or bypass it) but never force the instrument to a preconceived length. .R. the apical third must be instrumented by hand because curvatures can exist in both a mesial-distal and a buccal-lingual plane. has a shiny spot. but only where the file will progress smoothly to length.  Wipe the flutes of the K3 after every use. 13. Mounce / Dent Clin N Am 48 (2004) 137–157 147 Fig. Removal of the smear layer with liquid EDTA (SmearClear.E. In some canals. especially in the apical third. or has other defects. Do not allow debris to build up on the flutes of the files. K3 files (as with any rotary nickel–titanium system) are absolutely contraindicated unless preceded by creation of a glide path with small K files (sizes 6 and 8) up to approximately size 15 to true working length.  Check the flutes of these files after every use.  Do not force a K3 apically that resists advancement. SybronEndo) after final irrigation with sodium hypochlorite is optimal. If the K3 is bent or stretched. In delicate apical anatomy. resembling a pigtail. discard it immediately. Such canals are at risk for file separation and are best judiciously treated by hand. Do not allow the K3 to spin in place without apical movement for more than a second at any level of the canal.

Clinically. the files should not be employed a second time after use in a canal of severe or abrupt curvature. length of tooth.  Use an electric torque control motor with auto reverse to power the files at the correct rpm. as mentioned previously. (Courtesy of Arnaldo Castelucci. it is essential to radiograph the tooth from multiple angles including mesial. Preoperatively. DDS. K3 clinical technique Coronal-third and middle-third management Before making access. and distal. most manufacturers have endorsed a rotational speed of approximately 300 to 350 rpm for maximum efficiency (Fig. straight buccal.E.)  Although the K3 can be used in more than one clinical case. Patency is important primarily because its loss causes significant debris to remain harbored in the canal’s apical third (predisposing the case to failure). Mounce / Dent Clin N Am 48 (2004) 137–157 Fig. The TCM Endo III motor (SybronEndo) is such a device. and blockage can be a major factor in causing iatrogenic events (most commonly.148 R. canal curvature. an assessment of the number of roots. Florence. 14. . ledging and separated instruments). Italy. 16).

which is usually about 3 to 4 mm down the canal. and apical third last.10. Files never should deflect off access walls as they make their way into canals. and smaller canals accessed coronally with the 0.08 tapered files. The pulp chamber must be completely unroofed. Crown down instrumentation is desirable. 17). Crown down instrumentation implies that the coronal third is instrumented first. restorability.R. medium canals (upper second bicuspids. with the common lateral dentinal triangle removed at the cervical level in molars. upper central incisors. strategic tooth value.10 body shaper. For these smaller canals.E. canal calcification. the middle third second. access difficulties. enhancing access and coronal shape. or to determine whether treatment should be contemplated (Fig. to preoperatively visualize the final result.12 and 0. Coronal-third enlargement in larger canals (distal roots of lower molars. Such . The K3 body shaper is used to light resistance. and so forth) will be accomplished with the 0. periodontal status.12. After achieving excellent local aesthesia. 15.08 gains a ‘‘toehold’’ in the canal. after the 0. After all the canal orifices have been located. Mounce / Dent Clin N Am 48 (2004) 137–157 149 Fig. palatal canals of upper molars. the operator can go back with a larger 0. The diagramed instrumentation sequence ensures a crown down technique. and so forth must be made. access to the canal orifice is always straight line. the orifice is initially enlarged with the K3 enhanced-tapered body shapers. and so forth) will be accomplished with the 0. Such an evaluation will allow the operator to anticipate difficulties that might be encountered in subsequent treatment.

ensuring a crown down sequence). from which the operator can then perform the final apical preparation. and create ideal canal preparation shapes. These files are ideal for achieving deep body shape (described later) because they are highly fracture resistant.E. allow subsequent 0. Mounce / Dent Clin N Am 48 (2004) 137–157 Fig. Used in succession. as each smaller tapered file is used. .02. remove coronal restrictive dentin. 0.150 R. it will advance further apically. It is recommended to use an electric torque control motor with auto reverse to power the files at the correct rpm. initial exploration should occur in the presence of an EDTA gel (especially at the start of a vital case). enhance tactile control over the apical third. 16. these three body shaping files alone may take the operator to the junction of the middle and apical third or further. most manufacturers have endorsed a rotational speed of approximately 300 to 350 rpm for maximum efficiency. and debris should be flushed away with sodium hypochlorite (5. The initial chosen body shaper (canal size dependent) is followed by successively smaller tapered body shapers (ie. Clinically. and 0.04. Body shapers can be used as the master apical file if they slide easily down a canal or if used in a root in which a previous glide path has been created after apical scouting with K files.06 tapered K3 files greater penetration into the apical third than they could achieve alone.25%) and EDTA reapplied. enhance irrigation. The TCM Endo III motor (SybronEndo) is such a device.

in general. Taking rotary files into the apical third without prior exploration with K files as described later will increase the chance that the canal will become blocked with dentin mud. the file will separate. even at this level. severely curved and calcified canals.06 K3 with a tip size of 35 (or the appropriate body shaper) can be placed to at least midroot and. a 0. a ledge will be created. (B. it is essential to radiograph the tooth from multiple angles (only the straight buccal is shown). in some narrow. 17. Conversely. the glide path is created by instrumenting canals by hand with small K files in the middle third to a size 10 to15 K file before proceeding with K3 files of all types at this level. Despite the temptation to enter the apical third in these cases. slightly beyond.06 K3 with a tip size of 35 . After middle-third scouting with K files. When a glide path is indicated. however. the glide path may not always be needed. after canal location and opening of the orifice. After middle-third scouting with K files. if the 0. Mounce / Dent Clin N Am 48 (2004) 137–157 151 Fig. it may be advisable in the middle third to first scout with size 6 to 10 K files to ensure canal patency before using body shapers. depending on the clinical case. Clinical experience will dictate how much hand instrumentation will be needed in the form of a glide path before using body shapers and K3 files of all tapers. oftentimes.R. it will. C) Subsequent treatment with the K3 system. it is advised to take the K3 file only as far as it will advance without placing excessive pressure on the file and not take it into the apical third yet.E. in the vast majority of teeth. or worse. When the K3 body shapers fall easily into a canal. (A) Before making access.

risks apical blockage.E. then a 0. underpreparation. and pack properly. shape. Instrumenting the apical third first. (or the appropriate body shaper) will not progress to the desired level (the junction of the middle and apical third).06 K3 with a tip size of 30. (B) Subsequent retreatment and its attainment. Recapitulation and irrigation should be frequent as described earlier. and iatrogenic misadventure. 19. SybronEndo). 20. or 15 can be employed instead. A recently introduced state-of-the-art fourth-generation apex locator (Elements Diagnostic System. Deep body shape is a key component of achieving control over subsequent apical-third instrumentation and obturation. among other less than satisfactory outcomes.152 R. Mounce / Dent Clin N Am 48 (2004) 137–157 Fig. 18. ideally after every file. 25. Apical-third management and deep body shape The apical third is the most challenging root canal anatomy to cleanse. (A) A lack of deep body shape. without removing restrictive dentin in the more coronal two thirds. Coincident to the importance of crown down Fig. .

an apex locator reading should be taken and a radiograph exposed to verify the correct length and make any necessary adjustments. tactile control. Mounce / Dent Clin N Am 48 (2004) 137–157 153 instrumentation is the importance of creating deep body shape. 18). the operator should slowly and gently attempt to reach the estimated working length as determined by tactile sense and the radiographic preoperative estimate of root length done initially. a bleeding/moisture point measured by way of paper points (as popularized by Dr. Recently. Instrumentation in the apical third can only be done well using time.06 K3 files are generally inserted from a size 35 (or larger) to a size 20 or 15 (canal size.E. Beginning with size 6 to 10 K files. The body shapers described previously are ideal for the creation of this deep body shape to allow ideal irrigation. Vero Beach. Deep body shape is a key component of achieving control over subsequent apical-third instrumentation and obturation. This length can later be verified by a second apex locator reading after instrumentation is complete (before obturation). K3 files are then introduced in a crown down fashion with a sequence that either varies the tip size (with subsequently smaller K3 tip sizes of the same taper) or varies the taper (mixing the tapers of the instruments as the tip size diminishes) (Fig. recapitulation. 20). a glide path for subsequent K3 files is established to approximately a size 15 to 20 K file at this length. the files should be allowed to progress apically just as far as they want to go. patience. After a size 10 or 15 K file reaches the estimated working length. and ease of negotiation. Deep body shape refers to the final and ideal shape of a prepared canal at the junction of the middle and apical thirds.04 K3 . After true working length is reliably established and the aforementioned glide path is created. and a gentle touch as the watchwords. For smaller canals. Florida) at the true working length. it often must be carefully explored first with hand instruments to determine (like the middle third before it) the apical canal diameter. and attainment of hydraulic forces in the apical third during the vertical compaction of warm gutta percha (Fig. patency. and a gutta percha master cone-fit radiograph. David Rosenberg. Maintaining canal patency and leaving the foramen in its initial position and size is critical. curvature. Irrigation and recapitulation should be frequent. initial diameter of the apical foramen. With either of these methods. for example. This space might be considered the ‘‘gate keeper’’ to the apical third. the 0. These K files should be entered passively and never forced to reach a preconceived or estimated length. ‘‘Gauging the apex’’). calcification. SybronEndo) that is ideal for this purpose (Fig. a state-of-the-art fourth-generation apex locator was introduced (Elements Diagnostic System. the 0.R. 19). Using minimal apical pressure. After the apical third is opened (with deep body shape created). curvature. After true working length is established. and apical curvature dependent) and the sequence repeated until the desired apical diameter is achieved (see the following section. In the method that varies tip size. K3 files are introduced with larger to smaller tip sizes used in a coronal to apical direction until true working length is reached.

. enhanced tapered body shapers. Gauging the apex Before a master apical file can be selected. K3 files are introduced in a crown down fashion with a sequence that either (A) varies the tip size (with subsequently smaller K3 tip sizes) or (B) varies the taper (mixing the tapers of the instruments as the tip size diminishes). It is noteworthy that 0. to determine to what size the apex is patent. Mounce / Dent Clin N Am 48 (2004) 137–157 series could be used in a similar fashion. This technique is best described by an illustration: if a size 25 K file slides to the true working Fig.E.02 K3 files of varying tip sizes can be introduced into the sequence as needed.154 R. ETBS. 20. especially in small canals and to aid in creation of a glide path. it is important to ‘‘gauge the apex.’’ that is.

The final shape imparted to the canal by a given K3 file can be matched by a paper point and gutta percha point of the same taper (Autofit gutta . length and gives a resistance to apical displacement through the foramen. Mounce / Dent Clin N Am 48 (2004) 137–157 155 Fig.R. 21. SybronEndo). location. The final shape imparted to the canal by a given K3 file can be matched by a gutta percha point (A) and a paper point (B) of the same taper (Autofit gutta percha and paper points. then a K3 with a tip size of 30 or 35 with an appropriate taper (if it will advance passively) can be used to true working length to create shape above the foramen to give an acceptable cone fit.E. Gauging the apex allows shape to be created above the foramen while maintaining its size. and patency.

21). are desirable. The hybrid technique. if it will slide to length without deformation (after the canal is dry). . Intuitively. larger apical sizes. whereas LightSpeed rotary files are used for the final apical preparation (B). 22. even with the information gained by way of the paper points used as detailed earlier. These steps also facilitate subsequent obturation with the continuous wave of condensation obturation technique (System B obturation with the System B heat source. giving rise to the K3/LightSpeed hybrid technique.156 R. Mounce / Dent Clin N Am 48 (2004) 137–157 percha and paper points. created judiciously.E. A cone-fit radiograph with the gutta percha point in place before obturation confirms working length and appropriate preparation shape and is strongly recommended to assure the best results. SybronEndo) (Fig. Texas) are used for the final apical preparation. blending the two instruments. excellent obturation is possible for a multirooted molar in a matter of minutes without the necessity of leaving a carrier as required in carrier-based obturation techniques. A paper point of the appropriate taper. SybronEndo). some practitioners prefer using the LightSpeed to create a larger final apical diameter (eg. The K3 rotary nickel–titanium file system is used for coronalthird and middle-third shaping and the initial exploration of the apical third (A). Although K3 files can be used to shape the entire canal including the apical third. Such larger apical diameters can be associated with enhanced Fig. informs the operator of the actual taper of the prepared canal and simplifies cone fit. Variations on the standard K3 technique K3/LightSpeed hybrid technique One method using the crown down philosophy and gaining popularity is the hybrid technique whereby the K3 rotary nickel–titanium file system is used for coronal-third and middle-third shaping and the initial exploration of the apical third. and LightSpeed rotary files (LightSpeed Technology. the buccal roots of upper first molars can be instrumented to a size 50). After a cone-fit radiograph and usually minor adjustments. San Antonio.

ease of cone fit. Van Cleynenbreugel J.06 (Fig. Summary The K3 rotary nickel–titanium file system by SybronEndo is a state-ofthe-art rotary nickel–titanium endodontic instrumentation method that combines excellent cutting characteristics with a robust sense of tactile control and excellent fracture resistance. Progressive versus constant tapered shaft design using NiTi rotary instruments.R. Wevers M. 22).E. [2] Shafer E.36(4):288–95. Acknowledgement The author would like to thank Gary Carr. future possibilities for hybrid instrumentation techniques that combine the best features of K3 with other rotary systems (most notably the LightSpeed) hold promise. Van Meerbeek B.36:199–207. The smooth shaft of the LightSpeed files facilitates their use deep in canals with greater ease than many other brands of rotary nickel–titanium files. Beullens M. Shaping ability in simulated curved canals. it is noteworthy that before the employment of LightSpeed files to create a larger final apical diameter. Int Endod J 2003. Part 1. Florek H. the K3 should be taken to true working length. and cleaner canals in the apical third by virtue of the dentin and pulp removed at that level. Mounce / Dent Clin N Am 48 (2004) 137–157 157 irrigation. . Although it is a complete instrumentation system. Int Endod J 2003. Although the use of LightSpeed files is detailed elsewhere in this issue. Lambrechts P. generally in a tip size of 25 and taper of 0. and the Digital Office Program for Endodontists. Efficiency of rotary nickel-titanium K3 instruments compared with stainless steel hand K-Flexofile. References [1] Bergmans L. Excellence in Endodontics 2. Pacific Endodontic Research Foundation.

faster. When clinicians understand the rationale of a continuously tapered 0. 0011-8532/04/$ . CA 92612. E-mail address: HK5DENT@aol. This predictability of shaping has not only influenced instrumentation but also obturation results.2003. Baltimore. USA The past 10 years has been witness to many changes in endodontics.06 preparation. Koch). USA b The Johns Hopkins Hospital. Machined. As a result of this quest for a better. while at the same time. 2nd Floor. Primary cone fit no longer needs to be a struggle. The anticipated changes range from the idea of disposable endodontic products to the concept of a true hermetic seal when obturating the canal. the authors are confident that significant change will continue to come to endodontics. The Barba Plaza.1016/j. Before the specifics of this new ‘‘sequence file’’ are discussed. DE 19810-4448. but are there more advances on the horizon? As previously mentioned. It is hoped that this file and sequence will satisfy many of the current demands of modern root canal therapy. DMDa. however. the simpler it should be.Dent Clin N Am 48 (2004) 159–182 Real World Endo Sequence File Kenneth A.com (K. Real World Endo in partnership with Brasseler USA has developed a new endodontic file and sequence. the benefits of a fully tapered preparation must be reviewed. better.A. The authors firmly believe that the more sophisticated a concept. 23 Misty Meadow.see front matter Ó 2004 Elsevier Inc. Certainly not the least among the changes is the issue of making endodontics not only better but also simpler. doi:10. predictable shaping now makes a primary cone fit easy and precise. DDSb a Real World Endo. they will be stunned by how quickly endodontics can become simpler and more predictable. These changes are certainly welcomed.cden.06 preparation and perform it in a consistent manner. Koch. Dennis G. All rights reserved. and most important. 2114 Silverside Road. Paramount among these changes has been the introduction of nickel–titanium (NiTi) rotary instrumentation that results in consistent. The introduction of new technologies has resulted in endodontics becoming easier. predictable.*. and this trend will continue in the foreseeable future. Wilmington.11. Brave. Irvine. be user friendly. MD.004 . Real World Endo has been and continues to be a strong proponent of a fully tapered 0. simpler technique. There are multiple benefits to be gained * Corresponding author. and reproducible shaping.

40 mm. it can be determined that the width at D-10 for the new file is 0.06 taper file into a space that I have had problems using a 0. with variable tip sizes (eg.60 mm.10 file followed successively by a 20/0.04.02 to 0.04).02 taper. A variable-taper . the diameter at D-10 for the 40/0.08.04).40 mm). The ProSystem GT employs such a variable taper sequence.A.06 taper is not just three times the width of a 0.04 followed by a 30/0. have said that the biggest obstacle to endodontic success is the step back preparation. although the taper increased 100% (from 0. Again.40 to 0. Before the authors evaluate the potential benefits. Orange.80 mm. as do a number of other file systems such as Quantec and RaCe (Brasseler USA. and eventually a 20/0. Brave / Dent Clin N Am 48 (2004) 159–182 from such a preparation.02 taper?’’ The answer to the above question is no. Interestingly.06. however. Savannah. A second option is to use a constant-taper file system. the taper increased 100% (from 0. A question that clinicians often ask is ‘‘How am I going to place a 0. The authors.60 mm.02 taper? Isn’t a 0.160 K. California).04. this is why a fully tapered 0.06 taper rotary file can be used with minimal problems.20) is added to the previously calculated number to get 0. The apical tip size at D-1 (0. a 35/0. The authors strongly believe in using a constant-taper file sequence such as a 0. Real World Endo has been trying to get this point across at lectures and in print. 0. the diameter at D-10 for this file can be calculated to be 0. But what does this really mean? It means that the effect of taper is inversely proportional to the apical tip size. Georgia). however.04 file). A 0. In addition. This number is calculated by multiplying the taper (0. Consider the following example: A size 20. the issue of taper must be addressed. a 20/0. The proof is in the arithmetic. Koch. Two file systems that employ a constant taper are the Profile and the K3 (SybronEndo. the width at D-10 only increased 33. but the width at D-10 only increased 50% (from 0.40 mm. if the taper is increased from 0. and at D-10.02 to 0.06 taper file three times the width of a 0. When the taper is increased from 0. The clinician can use a sequence of files that employs a common tip size but has varying tapers (eg.G. and for the past 2 years. This finding is even more interesting. So. If the apical size of the file at D-1 is increased to a size 40 (0. the effect of taper decreases.04.06 taper to shape the root canal preparation.04 or 0. The authors could not agree more. would like to take this point one step further.04).04 can be determined to be 0. D. The authors agree with others who. a 25/0. a 20/0. The knowledge of taper also allows the clinician to understand that there are basically two ways to perform a root canal.04.02 to 0. the diameter is 0.02 taper file (20/0.33%. and finally a 20/0. as the size of the file increases.60 mm).20 mm at a distance (D) of 1 mm from the tip (D-1).02) by the length (10 mm).02) is 0. This is very significant because this is why a 0. that is. in effect.06 preparation can be performed and still have a conservative preparation.02 to 0.

06 preparation (performed in a crown down manner). The only way these areas can be effectively cleaned is through the use of an irrigation agent. The result is a lack of reproducibility that will make obturation more challenging. the amount of extruded material can be further reduced.K.06 preparation. pull debris coronally rather than push it in an apical direction.04 preparation. Two of the major benefits of the 0. A total comprehension of taper is absolutely critical to clinicians’ interest in increasing the quality of their endodontics. the removal of this tooth structure results in a dramatic increase in proprioceptive ability. . clinicians now have the ability. the irrigation agent is getting into the root canal system right from the start. Gates–Glidden burs make a parallel preparation in the coronal part of the canal.G. with a 0. along with increased patient satisfaction. How effective is the irrigation agent when a size 20 hand file can hardly screw to length? It is not very effective. reproducible shapes. to create predictable. in the authors’ opinion.06 preparation. Canals that are preflared with Gates–Glidden burs (and a 0. The root canal should be thought of as a three-dimensional system. D. Brave / Dent Clin N Am 48 (2004) 159–182 161 concept.06 preparation?’’ There are a number of reasons for this preference. The sequelae of this is increased postoperative sensitivity. does not work nearly as well clinically as it does on paper. the continuous 0. on the other hand. however. The variable-taper sequence results in a different shape each time a root canal is done. with a series of constant-taper files. Another aspect of the 0.04 taper) do not do as effective a job with irrigation as a 0. When one thinks about it. and anastomoses.02 or 0.06 taper allows the irrigation agent to work in a more efficient manner.06-tapered preparation are a dramatic reduction in postoperative sensitivity for patients and the ability to have a precise cone fit.06 preparation that contributes to patient satisfaction is the reduction in extruded debris.02 or 0. The irrigation agent has the ability to work much more effectively in a tapered 0. ‘‘Why do endodontists prefer a continuously tapered 0. This combination leads to predictability. by design. however. Furthermore. Therefore. Koch. ultrasonics are particularly effective in a 0. debris is pushed out past the end of the tooth.06 taper preparation due to the continuous taper. however.06 preparation compared with a 0. By using rotary files that. with webs. When performing a continuously tapered 0. Consequently. fins. In a sense. has superior hydraulics when it comes to irrigation. In fact.A. a variable-taper sequence is nothing more than a step back preparation from the opposite end of the tooth. however. A continuous taper. the question remains.06 preparation. In addition. this inoculates the periapical tissues. Quite often when performing a root canal with hand files. there are other benefits associated with a 0. one benefit of this technique is more tactile awareness. the larger taper removes the tooth structure in the coronal part of the canal that has a tendency to bind instruments. if not pain and swelling. As a result of better-quality manufacturing.

Instead of guessing. Most files are symmetric in their blank design. In fact. The 0.) The authors hope to change this tendency with the introduction of the Real World Endo Sequence File. they previously have been frustrated by one aspect. estimating. metal treatment (or lack of). Brave / Dent Clin N Am 48 (2004) 159–182 The authors firmly believe that endodontics can be accomplished in a truly painless manner.A. flexibility. resistance. It is not magic but a result of the 0. The authors have not been able to successfully teach (to their satisfaction) this technique to the majority of general dentists.06 preparation. When live demonstrations at Real World Endo courses are performed. there seem to be greater differences and less in common between the files. the 0. this becomes even easier when the main cone matches the preparation. during the manufacturing process. however. or becoming frustrated with bent cones. (It is the authors’ belief that a 0.06 preparation. Koch. however.162 K. The news about performing a fully tapered 0. Consequently. they all work better with a 0. the participants are always stunned at the ease of the cone fit.06 preparation.06 preparation and having a precisely sized cone. there are fairly significant differences between the various files. The authors can confidently state that whatever obturation method is used. and speed requirements. gets even better.06 preparation is a significant key to achieving this goal. there remains tremendous variability between the different files.G.06 preparation because the size no longer has to be ‘‘verified. Some of the areas where file design differs is in blank design. Consequently. True appreciation of this file is gained when its design features are fully understood and it is actually used clinically.06 cases. General rotary file design Blank design NiTi rotary files are ground. cutting efficiency. pitch.06 preparation makes the primary cone fit a ‘‘no-brainer.’’ Even though the authors have performed thousands of 0. although some . All endodontic companies are trying to produce files that will work more efficiently and safely. D.06 tapered files had a tendency to be sucked down into the canal or were quite stiff. Additional benefits of this technique come after a fully tapered 0. quality of NiTi manufacturing. as more rotary files enter the marketplace. tip design. helical angles.04 taper files or files with variable taper.06 preparation has been created: primary cone fit and ease of obturation.’’ Naturally. not twisted. taper. Even the solid core obturator systems such as Thermafil work better with a 0. the general practitioner has had a tendency to use 0.04 taper preparation should be performed only when the situation does not allow a fully tapered 0. This inability is because the previous 0.

Is the file running true (tight concentric revolutions) or is there a wobble? A wobble signifies a less than ideal manufacturing process. A good test of the quality of a file is to turn the file around and look straight down on the file as it is rotating in the handpiece. Depending on the blank design. This process is very significant because it has been repeatedly shown that crack nucleation and propagation is a leading cause of unexplained instrument separation. some companies are also producing rotary files in a 0. Brave / Dent Clin N Am 48 (2004) 159–182 163 have an asymmetric design such as the K3 by SybronEndo.A. Other manufacturers employ NiTi blanks that are stiff and actually seem to hold a curve. reduced engagement. Some manufacturers use NiTi blanks that exhibit extreme flexibility and excellent shape memory. D. which is the same International Standards Organization taper size as a hand file. Additional aspects of the quality of manufacturing can be seen if the handle of the file being used comes off during engagement. electropolishing will dramatically reduce the potential for crack propagation in NiTi files. Although the majority of rotary files have blanks that create significant engagement against the dentinal walls. Quality of manufacturing The adage ‘‘you get what you pay for’’ can be applied to endodontics. In addition. Surely. Koch.G. The quality of the NiTi blank is a little-known factor of file design but one that has serious consequences. Although . For example.K. there are other files such as the RaCe that have an alternating spiral design and. In fact. there are very few companies doing metal treatment of any nature to their rotary files. however. This concept is important because it must be remembered that excessive torque is one of the key factors in instrument separation. the more torque is required to work the files properly. The concept behind the metal treatment of rotary files is that such procedures can extend the life of a rotary file. Currently. most companies know the benefits of metal treatment procedures such as cryogenics or electropolishing. therefore. Taper The majority of manufacturers produce rotary files that come in a variety of tapers. there are different quality NiTi blanks that are available for commercial purposes.02 taper. making it a better file. certain rotary files can become extremely stiff in tapers greater than 0. Metal treatment Metal treatment has been greatly underused in the manufacture of NiTi rotary files. The greater the resistance.04. The blank design of a file is very important because it will influence the flexibility of the file and the lateral resistance.

be different. As previously mentioned.’’ Others have ‘‘guiding tips. a cutting tip on a nonlanded file. or a file that does not have a self-centering ability. Tip design Tips have been described as either cutting tips or noncutting tips. an elliptical tear is generally created. cutting tips have a limited indication in endodontics and should be used only in the hands of an experienced clinician. Furthermore. Cutting efficiency Cutting efficiency of rotary files is an area that has received much attention in the past few years. Is there a place for a cutting tip on a rotary file? The answer is yes. however. There are two serious concerns with a cutting tip. if the clinician goes long with a cutting tip. Real World Endo feels very strongly about this issue because their goal is to not only make instrumentation more efficient for the clinician but also maintain safety at all times. This tear is very difficult to repair and obturate.A. D. Rotary files with a positive rake angle and recessed radial lands may have seemingly better cutting efficiency. The more efficient a rotary file. in fact. Small radius curvatures are a common cause of instrument breakage. Real World Endo believes that most dentists are best served using a rotary file with a noncutting tip. The authors are very confident about that statement.’’ These claims are all a bit of semantics because a tip can actually be noncutting at the true tip but may become active before D-1 on the shank. . Although some experienced clinicians may be able to use cutting tips.02 taper rotary file is so small and flexible that it can easily get pulled into the small radius curvatures present in the apical third of many teeth.02 taper rotary files is a serious mistake for most clinicians. when the file is retracted. A 0. The first is if the clinician accidentally ‘‘goes long’’ (past the end of the tooth). the authors believe that they are too aggressive for most practitioners. The entire issue of rake angles continues to be one of controversy in endodontics. even for a specialist. the greatest safety cushion is afforded with noncutting tips. Brave / Dent Clin N Am 48 (2004) 159–182 a 0. Going long with a noncutting tip will create a concentric circle at the end of the root. however.G. If a clinician needs to use a 0. has the very real possibility of transportation. Nonetheless. the rake angle can. Depending on where a rotary file is sectioned. the less torque is required.164 K. Some files claim to have ‘‘modified cutting tips’’ or ‘‘partially active tips. the authors believe that using 0. Most manufacturers are attempting to address this challenge.02 taper may work well in the hands of certain specialists.02 taper file. Koch. These spaces are easily filled with a nonstandardized or tapered cone. Rotary files with full radial lands and a neutral rake angle have modest cutting efficiency. the authors’ recommendation is to use a hand file. however.

A reamer design (triangular). the more resistance generated. 1. . They helped keep the files centered and they reduced. Tulsa. is the sharpness of the cutting edge.G. Resistance Increased resistance will result in increased torque requirements. This was because many of the earlier designs of rotary files were based on hand files or screws. will have up to 50% less resistance than a true K-file design. Radial lands on rotary files (either full or recessed) will increase lateral resistance (torque) as opposed to a triangular blade design without radial lands.K. Precision tip after electropolishing. Another aspect. is not a good thing for rotary files. Fig. The less resistance created. D. To accomplish this task of not getting sucked down into the canal. on the other hand. In addition. however. Radial lands were a tremendous help with the first generations of rotary files. Electropolishing will greatly enhance the cutting efficiency of an edge (Fig. which as previously mentioned.A. 1). Koch. Brave / Dent Clin N Am 48 (2004) 159–182 165 Alternately. the smoother and safer a file will perform. A sharper edge can be achieved with a triangular blank design (without radial lands). the more spirals present on a blank (such as a hand K file). along with the process of electropolishing. Oklahoma]) exhibit increased cutting efficiency. the tendency for the file to get sucked into the tooth. to a lesser extent. files that employ a modified triangular bade design and progressive taper (such as the ProTaper [Dentsply Tulsa Dental. often overlooked.

Although the higher rate of speed may be beneficial. Basically. As you decrease the torque requirements. the flexibility of NiTi files has become a given. Variable helical angles are also an important aid to moving debris up and out of the canal. so long as it is variable. Pitch/helical angles Pitch is the number of spirals or flutes per unit length. Many things can effect flexibility. Speed Concerning speed and its influence in rotary instrumentation. will significantly decrease the tendency of the file to get sucked down into the tooth. This debris accumulation can lead to the need for increased torque. There is tremendous variation in flexibility among the various rotary files. however. A variable pitch. where E. it does not matter how the pitch is varied. on the other hand. is a function of both speed (S) and torque (T ). the energy required to remove dentin. One can actually see debris moving up along the shank of the file that has variable helical angles. The authors strongly believe that if clinicians are treating difficult endodontic cases in their practices. This is especially significant when using tapers of 0. blank design. Interestingly. Although it is true that design features can effect how well a file performs. and the presence and width of radial lands.A.06 or greater. not at too fast a rate. this concept means that a file will run better at a higher rate of speed (within reason) than at a lower rate.166 K. this is not truly the case. Pitch is very important because a constant pitch will work much like a wood screw and pull you into the tooth. the file cannot run as long before the onset of cyclic fatigue). Throughout the years. It is as simple as that.G. Brave / Dent Clin N Am 48 (2004) 159–182 radial lands sacrificed cutting efficiency along with creating increased resistance (torque). . It has been the authors’ experience to observe that clinicians usually run rotary files at too slow an rpm. E = S & T. Flexibility is not as critical in straight canals or teeth with very modest curvatures. Koch. the authors would like to propose a formula. then they need a file with excellent flexibility. which can lead to potential separation. A constant helical angle file is more prone to debris accumulation. it also decreases the cycles to failure (ie. such as the manufacturing process. one may increase the speed. flexibility still remains a critical factor for rotary files. D. Flexibility Flexibility is a design feature that received a lot of attention when rotary files first entered the marketplace.

This is because ACPs greatly reduce the resistance of the file (Fig. 2. D. . It is designed in such a way that there are alternate contact points (ACPs) along the shank of the instrument. the features of the new Real World Endo Sequence File are specifically examined. Real World Endo Sequence File design Blank design The blank design of the Sequence File is absolutely revolutionary. Fig.G. Koch. 2). This innovative design not only keeps the file centered in the canal but the ACPs also greatly reduce the torque requirements of the file.A.K. in a general sense. Brave / Dent Clin N Am 48 (2004) 159–182 167 Having discussed the design features of rotary files. (A) Sequence File with ACPs. (B) Diagrammatic representation of ACPs.

the Real World Endo Sequence File is the only constant-taper rotary file system that is subjected to an enhancement procedure such as electropolishing. but the Sequence File has been designed to be part of a single-use system. the lack of radial lands results in a decreased thickness of metal. On thorough inspection of a Sequence File. there is a certain connotation to Swissmade and the authors believe that the ‘‘proof is in the pudding. Electropolishing can extend the life of a rotary file. This design change is profound because the lack of radial lands allows the instrument to be sharper and. consequently. In addition. which is very significant because of the benefits gained from such a treatment. however.A. more important. Quality of manufacturing It is not sufficient to say that just because something is ‘‘Swiss-made. there is no need for radial lands. more efficient. After inspecting the edges. Because the ACPs. The authors believe that this is a significant advance in the manufacturing of constant-taper files. In addition.G. less lateral resistance. the shape memory of its NiTi blank. It also must be noted that at the current time. Simply put. keep the file centered in the canal. For example. . Electropolishing removes many of the imperfections in the NiTi that can have catastrophic consequences. one can confirm the sharpness: when the file is pulled across the fingernail (cuticle to tip). The shape memory is superb. electropolishing makes any rotary file safer and better (Fig. The result of less metal is a dramatic increase in flexibility. the creation of a superior finish will keep the edge of the NiTi instrument sharper. by rotating it slowly and checking the consistency of rotation. one can also confirm the flexibility of the Sequence File and. It is next to impossible to separate the handle from the shank. Metal treatment Another admirable feature of the Sequence File is that it has been subjected to the process of electropolishing.06 rotary file can be when not burdened by the excessive metal that is needed for radial lands. Koch.’’ Real World Endo is committed to the concept of ‘‘Precision-Based Endodontics. it will bite and engage. These cracks have been shown repeatedly to be a major cause of instrument separation. one should see a shadow consistently climbing up the helical angles from the tip to the handle. cleaner. and increased resistance to wear. 3). The result of these benefits is a rotary file with more cutting efficiency. in combination with a precision tip. D. and more durable.’’ and this precision is a function of the quality of manufacturing. On inspection. electropolishing is very effective at inhibiting crack propagation in NiTi blanks. The sharp edges are a function of its manufacturing process.168 K.’’ it means that it is excellent. Clinicians will be amazed at how flexible a fully tapered 0. Brave / Dent Clin N Am 48 (2004) 159–182 There are other significant features to the ACP design.

K. 3.A. D. (B) After traditional polishing.G. (A) Pretreatment view. . Koch. Brave / Dent Clin N Am 48 (2004) 159–182 169 Fig. (C) After electropolishing.

04 and 0. Consequently. A full working shank is significant because it will allow the practitioner to ‘‘machine’’ a preparation in a precise. 1) It is truly amazing how such an effective cutting file can remain centered in the canal. these are fully tapered files. Cutting efficiency The Sequence File has superb cutting efficiency. . D.06 tapers. After a brief period of time (3 to 5 seconds). A precision tip. The authors challenge any other manufacturer to meet these simple yet rigorous standards.G. Not only will this technique contribute to painless endodontics but it also will make the primary cone fit an easy match. the Sequence File uses a precision tip. Taper The Real World Endo Sequence File is available in both 0. The only other file that the authors have seen with a similar efficiency is the ProTaper. This accumulation is a result of the file’s superb cutting efficiency. the operator can actually see the flutes (which are a reamer design) begin to accumulate debris. which means that the working shank is 16 mm. is a nocuutting tip that becomes active right at D-1. Obturation becomes much easier when you have a fully tapered machined preparation. Brave / Dent Clin N Am 48 (2004) 159–182 It is with supreme confidence that the authors can say that the Sequence File has been manufactured to the highest possible standards. The file should be in the canal only for 3 to 5 seconds before cleaning. Koch. This is exactly what we want to have in a tip design (see Fig. What gives the Sequence File extra cutting efficiency is the electropolishing that results in its characteristically sharp edges. Although the ProTaper also employs a triangular bank design. the ACP design allows the portion of the instrument that is engaged to really work in an efficient manner because the full shank is not totally engaged and there is no encumbrance of radial lands. not a reduced 9 or 10 mm. the operator and the assistant need to be conscientious about cleaning the file. The result is safety (nonperforating) combined with efficiency. This ability to remain centered is the result of a precision tip combined with ACPs of the blank design.170 K. Consequently. Tip design It is a goal of Real World Endo to have clinicians perform not only efficient endodontics but also safe endodontic procedures. Experience has shown that the Sequence File cuts so effectively that the operator must be aware to wipe clean or change the file after three pecks (or engagements) of the file. Furthermore. Most important. it is somewhat modified.A. This concept is a new and revolutionary one. by definition. crown down fashion.

Koch. there is no transportation. Flexibility As previously mentioned. endodontists will always continue to be challenged by more difficult cases. To consistently achieve Precision-Based Endodontics. it nonetheless has excellent debris removal as a result of its variable helical angles. the need to have a flexible file becomes paramount to perform quality endodontics. Best of all. results in greater flexibility of the file. extremely sharp edges. or 30 may be extremely difficult and frustrating. the flexibility of this file is outstanding.A.G. The following attempt to enlarge this preparation to a size 20. and lack of radial lands. Control over the file means control over the procedure. electropolishing. For example. The manufacturer has combined all these features into a single file. which is a result of its triangular reamer-like design. It is astonishing how the Sequence File is quickly able to enlarge the preparation to a size 25 or 30. 25. Brave / Dent Clin N Am 48 (2004) 159–182 171 Another wonderful aspect of its cutting efficiency is how well and how fast the Sequence File can enlarge a canal preparation. The net result of these features is greater control. many times a clinician may be able to reach the working length of a mesial buccal canal (in a lower molar) with only a size 15 file. precision tip. D. . manufacturing excellence must be combined with clinical control. Flexibility becomes a tremendous asset in rotary endodontics as the clinician begins to tackle more difficult cases. which is further enhanced by its blank design (ACPs) and the lack of radial lands. and excellent flexibility. The result is less of a tendency to pull down into the canal.K. without question. This ability of the Sequence File to withstand transportation is a function of its ACPs. without the need for radial lands. generates the least lateral resistance of any constant-tapered rotary file system. The key point to remember concerning flexibility is this: flexibility is not the same among the various rotary files and it most certainly should not be taken for granted. Consequently. Pitch/helical angles The Sequence File has both variable pitch and variable helical angles. Resistance The Sequence File. The ability to create a file that stays centered. Although the Sequence File is very efficient at cutting. In fact. Clinicians will immediately notice the difference when comparing the ability of the Sequence File with any other fully tapered landed file to withstand transportation. with the result being the lowest torque requirements of any constanttapered rotary file system.

but at other rpm. If the clicking becomes a clacking (or clearly noisy). however. the Sequence File runs superbly in a portable handpiece. portable engines have been challenged when running fully tapered 0. however. . this clicking might have been cause for alarm. however. Brasseler Sequence File portable handpiece.A. Every engine the authors have worked with seems to have an optimal rpm for specific files. In the past.172 K. it is not unusual for a triangular-shaped blank. The day is coming when clinicians will be able to perform rheostat-free endodontics. The ideal speed may vary a little according to clinician preference and engine. This concept is analogous to marine engines in which a boat will plane and perform smoothly at a certain rpm. Historically. D. 4. Brave / Dent Clin N Am 48 (2004) 159–182 Speed The Sequence File has been shown. not rpm. to work best in a range of 450 to 600 rpm. the boat will experience some noise and vibration. The authors’ personal preference is 600 rpm. which they have found to work well in multiple engines. Koch. then it means that you are pushing too hard on the file.06 rotary files because the radial lands on the previous generations of rotary files produced excessive lateral resistance. It also is a goal of Real World Endo to remove as many rheostats as possible from the treatment room. It must also be pointed out that the Sequence File has a tendency to click in the canal. The rpm should not be reduced because the clacking is a result of excessive force. The authors particularly like the way this file performs in a portable engine (Fig.G. through test cases (both clinically and bench top). 4). The clacking will disappear when the file is not pushed as hard. Due to the ACP design (no lands) and its lack of torque requirements. Fig.

then it will be open all the way to the apex. D. and the operator chooses which package of files to open. Koch. This decision is based on information gleaned from the preoperative radiograph. The use of an Expeditor is a new concept.G.K. the following section addresses clinical technique. Real World Endo Sequence File technique The Real World Endo Sequence File comes in packages of four files each. Having met resistance with the Expeditor. All root canal preparations are begun by confirming coronal patency. 5). A totally loose Expeditor that goes to its entire length signifies a large canal. The selection of Sequence Files includes an Expeditor file (four to a pack) and 0.A. the resistance of the size 10 hand file. The Expeditor is a size 27. After reaching the halfway point in the canal. using a totally different file. If the canal is extremely tight. medium. this file is taken down into the canal until significant resistance is encountered. the size 10 file is ‘‘worked’’ in a back and forth motion to ensure a glide path.06 taper rotary files in sizes extrasmall/small. After coronal patency has been confirmed. Now that the design features of the Sequence File have been discussed. . Significant resistance is when the file no longer progresses in an easy manner. when the Expeditor goes down more than halfway. Brave / Dent Clin N Am 48 (2004) 159–182 173 In the authors’ experience. it means the canal is medium sized. then the clinician may also wish to use a size 15 hand file. an Expeditor file is the first rotary file placed into the canal. there are 0. this file is now removed from the canal. 0. it signifies a small canal. This breakage takes place because the file is going so slowly that there is a tendency for the clinician to force the file. After the canal size is determined. efficiency combined with safety). By running the handpiece at the proper rpm (450–600 rpm). After entering the canal with the Expeditor. however. the operator simply picks the appropriate pack of files. When the Expeditor goes down halfway into the canal.04 taper rotary file that incorporates a working shank of 16 mm and an overall length of 21 mm (Fig. rotary files that are run at too low a speed (150–175 rpm) result in increased breakage. A file should never be forced. The purpose of the Expeditor is to determine the approximate size of the canal and which package of files should be opened. and the depth of penetration of the Expeditor. In addition. the clinician can let the file do the work. The authors have given the Expeditor an overall length of only 21 mm so that the clinician does not get tempted to ‘‘bury’’ the file deep into the canal (ie. and large. This confirmation is achieved with a size 10 stainless steel hand file that is taken down half way into the canal.04 taper Sequence Files available in sizes extrasmall/ small and medium. Coronal patency is important because if the coronal half of the canal is open (patent).

crown down should be continued to a 15/0. a 25/0. The question remains. In this case.174 K. the 20/0. For example. D.G. a crown down technique is performed in the recommended manner. in a narrow canal. in a small canal. If the canal is narrow and the clinician must crown down all the way to the 15/0.06 file. the author takes that to resistance. this file should take the clinician to the final working length. however. Quite often.06) file. There will be times. Following the initial file. the authors suggest that the preparation should not be finished with this size instrument.06 file are taken to resistance. It is better to . ‘‘How do you know when you are finished?’’ The crown down preparation is complete after the first rotary file that reached the working length with resistance has been used. however. 0.06 file.06 taper (30/0.06 Sequence File falls short of reaching the working length with resistance.06 Sequence File will take the author to the working length. and generally.06 Sequence File and then a 20/ 0. when the 20/0. Brave / Dent Clin N Am 48 (2004) 159–182 Fig. the package of extrasmall/small files may be chosen.A. 5. Koch. After choosing the appropriate Sequence File. Sequence Expeditor file. For example. beginning with a size 30.

Real World Endo Sequence File technique for extrasmall canals As always. in extremely difficult. The Expeditor is worked down into the canal until significant resistance is met. This procedure is easily accomplished because the Sequence file is extremely efficient at enlarging a previously created glide path. The modified crown down preparation begins with a size 25. 0. however. the Expeditor is introduced into the canal. Following the use of the Expeditor. the clinician begins by confirming coronal patency with a size 10 stainless steel hand file. The final working length may now be determined with a size 10 stainless steel file and an apex locator. After two files. This increased length is what is so effective about this technique. Following length determination. which will readily go to the working length.06 Sequence File. If not. This step is extremely important when treating narrow canals. the authors slightly modify the technique to reduce stress on the file. The aforementioned technique works very well for the overwhelming majority of cases. Brave / Dent Clin N Am 48 (2004) 159–182 175 simply go back into the canal with a 20/0. The authors do not advocate finishing the preparation with a size less than 20. it now tracks down to about 18 mm. . the clinician takes the 20/0.06 file.06 fully tapered preparations.A.04 and 0. This applies to both 0. when crown down must go all the way to size 15. narrow canals. the coronal half of the canal has been successfully preflared.06 file and works this file to resistance. Instead of just going to 15 mm. Following this step.06) Sequence File.06 Sequence File and taking this to length.K. the authors recommend looping back with a 20/0. Although the modified crown down works extremely well in difficult cases.06 taper (25/0. The clinician may chose to create a glide path to the apex with a size 10 or size 15 hand file.04 taper rotary files instead of 0. however. Koch. D. Often. the clinician returns to the original 25/0. taken to resistance. It is also suggested to take a size 15 hand file into the canal and create a glide path. this file goes down the canal about 15 mm and should be followed with a 30/0.06 file to resistance. A modified crown down sequence will be substituted for a straight crown down. the size 20 will reach the final working length.06 taper instruments. Following the use of the hand file. but with one modification.G. The crown down procedure can begin. This file will generally go 1 to 2 mm less. one further change can make the technique easier: performing this technique with 0. Generally. which will generally reach final working length. As previously mentioned. the clinician should open the package of files labeled extrasmall/ small. This procedure will facilitate the rotary instrumentation in such canals.06 Sequence File. the crown down should be continued with a 15/0.

Brave / Dent Clin N Am 48 (2004) 159–182 Fig. Summary In review. Case 1. medium. this change is exactly what is needed to instrument these challenging cases (ie. it is all a function of taper). D.02 taper hand filing case. (A) Failed 0. (B) Successful retreatment with 0. Often. Koch. The canal size is either small. the entire Real Word Endo Sequence File technique is based on the concept of using an Expeditor file and then choosing the size of the canal. and each corresponding package contains the four files necessary to properly shape the .06 taper rotary files. or large.G. 6.176 K.A.

Koch. however. (A) Preoperative radiograph of mandibular molar. (B) Postoperative radiograph showing machined preparations. (Courtesy of Dr.’’ then a clacking of the instrument is heard. This is a ‘‘heads-up’’ to reduce the pressure on the file. Ali Nasseh. it should not be forced. but a fourth file has been included for challenging cases (Figs. D. Brave / Dent Clin N Am 48 (2004) 159–182 177 Fig.) canal. the clinician . When the proper technique associated with this file is learned. 7. Generally. Although the Sequence File is unique in being both procedural and precision based. As previously mentioned. Case 2.G. It is a rotary file. if this file is ‘‘muscled. 6–10). the canal preparation will require only three files.K. and like all rotary files.A. it is also different in terms of its handling ability.

This is a result of its superb cutting ability. (C) Postoperative radiograph. Case 3. (A) Midroot ‘‘area’’ on mandibular premolar. (B) Working film displays precision of preparation.178 K. the unique ACPs gives this file an unbelievable ‘‘feel. the entire procedure can be made very comfortable when combined with a portable handpiece. The clinician needs to establish a firm finger rest when using rotary files. In addition.A. D.’’ The canal can actually be felt with the Sequence File. This change from some of the previous rotary files that were stiff and lacking in sensitivity is a welcome one. Ali Nasseh.G. (Courtesy of Dr. Koch. Brave / Dent Clin N Am 48 (2004) 159–182 Fig. 8. This concept also is important with the Sequence File.) will realize that it is merely a matter of guiding the instrument. .

Always clean the file after three engagements. the file should be slightly retracted (1–2 mm) and then reinserted for another engagement. 8 (continued ) The Sequence File is not used like previous rotary files that had radial lands. to engagement (2) and back. The clinician will very quickly learn this rhythm. What is meant by engagement? When performing this technique. the clinician can actually feel the Sequence File engage the walls of the canal and begin to work. Koch. So. a rotary file that is controlled by finger tip pressure. D. that is. for the first time. . and so forth. it is used in a single ‘‘1-2-3’’ motion. we now have. By using this technique. the clinician is instrumenting the canal millimeter by millimeter. and finally to a third engagement (3).A. It is the rhythm of precision endodontics.G. landed files). and out of the canal. The portable handpiece allows clinicians to work strictly with their fingers (thumb to middle finger). As soon as the clinician feels the file engage. The Sequence File also is not used with short staccato-like pecks. instead of controlling the file from the wrist area (as is done with thicker. the file is not taken to resistance and back. to resistance and back.K. It is recommended that the clinician perform two series of three engagements each before going to the next file. Each series of engagements should take approximately no more than 3 to 5 seconds. The file is taken to engagement (1) and back. Brave / Dent Clin N Am 48 (2004) 159–182 179 Fig. This adds greatly to the overall control of the procedure and will more easily allow the clinician to achieve Precision Based Endodontics. Instead.

Case 4. D. If a canal is patent in the coronal third. Begin crown down.) The following list reviews the basic Real World Endo Sequence File technique: 1. The file only needs to go to approximately one half of the projected working length. 4.A. 9. Establish working length after second file from Sequence File package. (B) Completed case showing conservative aspect of machined preparations. Koch. Obturate the canal. (A) Preoperative radiograph of maxillary bicuspid. (Courtesy of Dr. Use Expeditor to determine canal size. 3. Confirm coronal patency. Brave / Dent Clin N Am 48 (2004) 159–182 Fig. Complete crown down. The following list reviews the basic Real World Endo Sequence File technique (straight crown down): 1. then it usually will be . Confirm coronal patency with a size 10 stainless steel hand file. Emanuel Alvaro.G.180 K. 6. 2. 5.

2.A.K. D. Determine canal size based on the preoperative radiograph. Establish working length with a size10 hand file and an apex locator after using the second rotary file from the package. or large. . Begin crown down with a file from the appropriate file-size package. (Courtesy of Dr.) open to the apex.G. 3.C) Working film displaying precision of Sequence File cone fit. Ali Nasseh. medium. the fit of the size 10 stainless steel hand file. Case 5. (A) Preoperative radiograph of molar. Koch. Brave / Dent Clin N Am 48 (2004) 159–182 181 Fig. 4. 10. Determine working length after the second rotary file to take advantage of the crown down. and the depth of penetration of the Expeditor. (B. Canal size is generally small. Too many dentists make the mistake of trying to force a hand file to length before coronal flaring.

Obturate the canal with the technique of your choice. completes the preparation.182 K. D. Complete rotary preparation in a straight crown down fashion. The first Sequence File to length. . 10 (continued ) 5. with resistance.G. Koch. 6. Brave / Dent Clin N Am 48 (2004) 159–182 Fig.A.

With most NiTi systems. School of Dental Medicine. guiding the instrument—stable and balanced—within the canal. doi:10. Philadelphia.11. University of Pennsylvania.2003. Nevertheless. it is easy to reach working length and prepare the apex to a small size such as International Standards Organization (ISO) size 20. dent. 1B). The radial land touches the canal wall on its entire surface.cden. PA 19104-6030. Among these systems. 81373 Mu¨nchen.* Department of Endodontics. two main categories of NiTi rotary instruments need to be differentiated: active and passive instruments. In general. Germany. Active instruments have active cutting blades similar to the K-FlexoFile (Fig. 1A). E-mail address: hewalsch@yahoo.1016/j. the limits of a particular system quickly become apparent. When the apex is prepared to larger sizes. quick. med. 240 South 40th Street. All rights reserved. The hybrid concept combines the best features of different systems for safe. those who have gained some experience in the use of such instruments will confirm that each file system has its own special advantages and disadvantages and that particular rules for its usage need to be followed.003 . USA The development of nickel–titanium (NiTi) rotary instruments is undoubtedly a quantum leap for the field of endodontics. whereas passive instruments have a radial land between cutting edge and flute (Fig.Dent Clin N Am 48 (2004) 183–202 The hybrid concept of nickel–titanium rotary instrumentation Helmut Walsch. The idea of the hybrid concept is to combine instruments of different file systems and use different instrumentation techniques to manage individual clinical situations to achieve the best biomechanical cleaning and shaping results and the least procedural errors. and their main features are described. MS. Dr. Nickel–titanium rotary instrument systems Some NiTi rotary instrument systems that presently can be used for this hybrid concept are introduced here. active * Heiterwanger Strasse 6. however.see front matter Ó 2004 Elsevier Inc. and predictable results.com 0011-8532/04/$ .

184 H. LightSpeed. (D) K3. Flexmaster. Key features of all instruments introduced here are three blades and a passive. the more aggressive the cutting action of the instrument. RaCe. Texas). (B) ProFile. instruments cut more effectively and more aggressively and have a tendency to straighten the canal curvature. the more positive the rake angle of the blade. ProFile (Dentsply Tulsa Dental. LightSpeed (LightSpeed Technology Inc. (A) K-file. noncutting tip. GT (Dentsply Tulsa Dental). Walsch / Dent Clin N Am 48 (2004) 183–202 Fig. (F ) ProTaper F3. Tulsa. File cross-sections. and others belong to the family of passive . GT.. Oklahoma). San Antonio. (E) ProTaper. and have less of a tendency for canal straightening. 1. In addition. (C) Hero 642. Passive instruments perform a scraping or burnishing rather than a real cutting action. remove dentin slower.

in contrast to these instruments. K3 (SybronEndo.06. ProTaper (Dentsply Tulsa Dental).185 H. The main advantage of this system clearly is its undefeated ability to manage curves with large instrument sizes because of its shaft flexibility.04 in size 15 to 80. They come in 0. West Collins Orange.06 in size 15 to 50.12.216 0. When using LightSpeed. At present. 1B). and 40).775 1. France).06 tapers from size 2 (0. and even large apical preparations can be performed with little deviation [2]. Georgia). LightSpeed. Representatives of passive instruments ProFile instruments come as ISO-sized instruments with a taper of 0. Germany). The size 20 set consists of five instruments with an additional taper of 0. Also available are Series 29 ProFiles for which the increase in size is 29% from one instrument to the next. LightSpeed instruments have been shown to maintain severe canal curvatures [1]. Flexmaster (VDW. It has a small cutting head with minimal cutting surface and has a thin parallel shaft. Their crosssection through the cutting head is similar to that of a ProFile or a GT file (see Fig. and others are active instruments. 0. These instruments come in half sizes from 20 to 70 and in full sizes from 80 to 100. Munich. they come as sets of differently tapered instruments and constant tip sizes (20. RaCe (Brasseler USA Savannah. no instrument size must be left out.600 0. a taper of 0. 30. Table 1 Series 29 instrument sizes Size No. and 0. Disadvantages are the high number of instruments per set and the need for a step back preparation in combination with constant recapitulation to avoid apical debris retention. 0. GT files for crown down and apical preparation have undergone several size modifications. Hero (MicroMega SA.360 0. California). Size (mm) Color code 2 3 4 5 6 7 8 9 10 0. The size 30 and 40 sets consist of four instruments with tapers of 0.129 mm) to 10 (1. LightSpeed instruments are used in a pecking motion with higher rotational speeds than all other NiTi rotary instruments. Besancon.167 0.04.10.000 Silver Gold Red Blue Green Brown Silver Orange Red .04 and 0.08. Walsch / Dent Clin N Am 48 (2004) 183–202 instruments.0 mm) (Table 1). features a design similar to that of a Gates-Glidden (GG) bur.279 0.465 0.129 0. and a taper of 0.02 in size 15 to 45.

very similar to that of FlexMaster (see Fig. from the moment when the blade touches the inner wall of the elbow of the curve to the moment when the flute is touching that point. a clicking sound can sometimes be heard. revealing that these are very strong instruments.’’ follows the idea of varying the instrument tapers [3]. The flutes of NiTi rotary instruments with regular helical angles (screwlike form) will only touch the inner surface of the elbow of a canal curvature for a short distance. the instrument straightens slightly. no helical angle) of a RaCe instrument might touch the inner surface of an elbow at a longer distance.06/20 to 30. They come in tapers 0. When an active instrument is rotating within a curve with a small radius. These instruments are very flexible. may compensate for this effect. Walsch / Dent Clin N Am 48 (2004) 183–202 Representatives of active instruments RaCe instruments come in the following taper/size combinations: as PreRaCe instruments—0. whereby the blades are straight for a short distance and parallel to the long axis of the instrument (alternating cutting edges).04/25 to 35. The straight part (straight flutes. The recommended usage. The particularly high flexibility of RaCe instruments. 1C. One reason for this clicking could be that the file breaks loose the dentin into which it was engaged.186 H. These instruments are relatively strong. and as RaCe instruments—0. The cross-section of Hero instruments is shown in Fig.06 and 0. Hero 642 instruments come in tapers of 0.06 and 0. Their cross-section is triangular with large flutes (see Fig. The amount of torque needed to cause the instrument to jump may be higher. ProTaper instruments have a convex triangular cross-sectional form.08/35. 1E). shown in Fig.02/15 to 40 and 50 and 60. . They have a convex triangular crosssectional form.04 tapers in sizes 15 to 60.06 and 0. Hero Apical instruments are accessory instruments for apical enlargement.06/30 and 40. called the ‘‘three wave concept. 0. it stands still at the elbow with the flute contacting the elbow until the amount of torque load onto the instrument exceeds the torque needed to force the instrument to rebend to get the blade to ‘‘jump’’ over the elbow again. 0. 1E. causing more straightening of the file compared with a regular file. 1D shows their cross-section. Fig.06 and 0. Another possible reason is the following: during the rotation of a file in a considerably curved root canal. 1A).04 in sizes 20 to 40 and in taper 0. 0. K3 instruments come in 0. FlexMaster instruments come in tapers of 0.04 in sizes 20 to 30 and in taper 0. Their main feature is that the helical angle after some revolutions has short interruptions (becomes 0 ).02 in sizes 20 to 70. This ‘‘jumping’’ from flute to flute can cause the clicking noise. and also are relatively strong.08 in size 30 and have short cutting areas. These instruments are relatively flexible. however. While the file continues to rotate coronal of the elbow of the curvature. The purpose of this feature is to reduce the screw-in effect of the instrument.10/40.02 in sizes 20 to 45. 0.

Active instruments can lead to procedural errors faster than passive ones in inexperienced hands. Clean and check files after each insertion. F3). whereas the F instruments have a decreasing taper from tip to top. This effect will reduce the torque load and increase the cutting efficiency of each individual instrument. recapitulate.H. at 3 mm. it is size 57. S1. the frequency of instrument deformations and fractures decreases [6]. some basic rules should always be obeyed.5]. . Keep canals flooded with sodium hypochlorite during instrumentation. Rotate files continuously. Irrigate. Experience using the instruments on extracted teeth before clinical use is mandatory. is 9%. The convex flutes of the largest instrument (F3) have been cut out to a more convex form. reducing the stiffness and increasing the flexibility of this strong instrument (Fig. the taper at 3 mm from the tip. A set of ProTaper instruments used sequentially will only cut along a short distance in the canal. It has been shown that with increasing experience. Use no apical pressure. however. Make each file insertion deeper with the same file. touching little canal wall surface. The main difference between the S and F instruments is that S instruments have an increasing taper from tip to top. F2. Minimize cutting time. S2) and three finishing instruments (F1. 1F). At 2 mm from the tip. increase file control. The tip size of F3 is 30. Shapers mainly cut in the middle third of the root canal with their tips. Walsch / Dent Clin N Am 48 (2004) 183–202 187 ProTaper instruments are unique among all NiTi rotary instruments in that they have different tapers along a single instrument (multitapered instruments). the diameter is size 48. Most of these rules seem even more critical for active instruments than for passive ones. Support operator’s hand at the neighboring teeth to compensate for patient moving. Use file lubrication (RC-prep [Premier Dental. and reirrigate after each file insertion. The following most important rules apply for the use of any NiTi rotary instruments: The lowest recommended rotational speed seems safest [4. Plymouth Meeting. The set consists of six instruments: three shaping instruments (SX. Check patency frequently. following the glide path so as to create an access for the finishers that will cut in the apical third of the root canal. Pennsylvania] or similar). Nickel–titanium instrumentation rules To increase the safety of NiTi rotary instrumentation techniques. and avoid the screw-in effect. Withdraw immediately at desired length.

Repeating the use of such a series of files will also result in either gaining deeper access into the canal or enlarging the canal further by each sequence. Crown down The crown down idea is to step apically by using a series of files while decreasing instrument size or instrument taper. and 0. eases instrument Fig. Fig.188 H. therefore. Crown down approach with decreasing taper. 2 indicate the areas where the individual instruments engage the dentinal walls. The tip size of each instrument is ISO 20. The next smaller file will perform its cutting action deeper in the canal. .10 (red).08 (yellow).06 (silver). 0. 2. The arrows in Fig. 2 shows the decreasing taper approach with a classical GT file set. leaving the engaging surface of each instrument minimal and. decreasing the torque load of each instrument. Walsch / Dent Clin N Am 48 (2004) 183–202 To understand the concept of a hybrid sequence of biomechanical instrumentation. three different approaches to enlarging a root canal (crown down.12 (blue). Crown down minimizes coronal interference. Arrows indicate corresponding cutting area. and apical widening) are summarized in the following sections. 0. with tapers of 0. step back.

step back is essential for different steps of instrumentation.H. body shaping. reduces canal curvature. and less torque compared with step back. and less procedural errors. reduces the contact area of each instrument (therefore reducing torque and increasing cutting efficiency and safety). The different steps of the biomechanical instrumentation [9] should be performed in a crown down manner in the following order: access cavity. Ideal preparation The ideal preparation form for the hybrid concept takes its pattern from the definition by Herbert Schilder [8] and is slightly modified: ‘‘a threedimensional continuously tapering cone in multiple planes with sufficient apical enlargement preserving foramen position and size’’ (modification in italics). more visibility and control over the area of dentinal wall removal. glide path creation. Step back The step back idea is to enlarge apically first and then step coronally by sequentially increasing instrument sizes or taper (flaring) for each instrument of a file series. This approach is particularly important for the last steps of apical instrumentation. As a result. master apical file (MAF) size determination. Apical widening The apical widening idea simply describes using a series of files in increasing order to enlarge the apex by using all files to the same length. With tapered instruments. A direct comparison between crown down and step back has shown that using crown down will result in less tip contact. taper lock (staying with a constant instrument taper) should be avoided whenever possible because varying the taper . less force. removes bacteria before approaching the apical canal third (therefore preventing iatrogen apical contamination). increases apical tactile awareness. apical enlargement. Nevertheless. minimizes change in working length during apical instrumentation. the general instrumentation approach preferably should be performed crown down. For best cutting efficiency. The benefits of working in this order include less risk of iatrogen contamination. straight line access. and reduces the instrument tip contact and the incidence of procedural errors. Walsch / Dent Clin N Am 48 (2004) 183–202 189 penetration. allows irrigation penetration to preparation depth. better access for irrigants. crown down is safer than step back [7]. working length determination. apical finishing). however. and apical preparation (apical pre-enlargement. a combination with step back and apical widening is often needed. apical LightSpeed instrumentation.

and different systems have different properties that should be used where they work best within the hybrid concept. 3. electronic apex locator. paper point control. A chronologic description of all the steps of biomechanical instrumentation using the hybrid concept is given below. Different canal—different approach For all steps of root canal preparation. therefore. It will decrease the coronal interference and. the GG sequence needs to be reversed. This sequence can be repeated. Therefore. The straight line form eases the penetration of the irrigation solution and following instruments. an understanding of where each instrument performs its cutting action in the canal is needed. . A GG bur size 1 compares to a file size 40 to 50. from size 1 to 4. there is no ‘‘one perfect system’’ of NiTi rotary instruments for all cases. There are five methods available (differently angulated radiographs. Straight line access After achieving an ideal access preparation outline. and gaining access into the root canals. patient sensation). In cases with more curvature. increase control over the instruments. and a GG bur 4 to size 100 to 110. Walsch / Dent Clin N Am 48 (2004) 183–202 during instrumentation will reduce the contact area of the instrument with the root canal wall and. and in cases with little curvature. a GG bur 3 to size 80 to 90. a considerable part of the body shaping (a later step of instrumentation) is already completed because a high percentage of dentin removal has been accomplished. tactile sense. In calcified cases. A straight line form can be gained by removal of the dentinal overhang in the outer aspect of the orifice and coronal third of the canal. a GG bur 2 to size 60 to 70. reduce the torque load and increase the cutting efficiency and safety. as described later. removing calcifications. the coronal third of the canals needs to be straight lined to minimize the coronal aspect of the curvature (Figs. Not every clinical situation can be managed with one particular system.190 H. a combination of at least the first two should be used on a regular basis. Straight line access can be achieved with GG burs in descending order from size 4 to 1 or with orifice shapers. therefore. Working length The next step is the working length determination. more body shaping needs to be performed with NiTi rotary instruments later on. 4). Different canals require different approaches.

Anatomic investigations confirm that in many cases. In determining the minor initial canal diameter at the working length. is not round in shape but consists of a minor and a major aspect (minimal and maximal diameter). one will find the first smallest . Starting from a small instrument size. Both studies are in agreement that there is a tendency to underestimate the original apical diameter. Moreover. the use of a LightSpeed instrument has been shown by Levin et al [12] to be more accurate than a K file (one versus three ISO sizes too small. Straight line access in an upper molar. The apical cross-section of a root canal in most cases. (B) After straight line access. should—among other criteria—be based on the original apical canal diameter: ‘‘the optimal enlargement of each canal should be calculated. . by increasing the file size. 3. the original apical diameter is size 30 or 40 or even larger [14–17]. (A) Before straight line access. on average). Another similar study reported a measurement of up to three ISO sizes too small with LightSpeed and up to four ISO sizes too small with a K file [13].based on the initial size of file that binds at the apical portion of the canal’’ [10] and ‘‘the apex should be enlarged at least three sizes greater than its original diameter’’ [11]. Master apical file size The apical canal enlargement to the desired MAF size. there is currently no way to estimate the major original apical canal diameter clinically. buccal canals. Walsch / Dent Clin N Am 48 (2004) 183–202 191 Fig. however. .H. (C) After completion of instrumentation. It is advisable to determine the minimal apical diameter with a LightSpeed instrument after determining the working length.

however. this goal cannot be achieved. however. Walsch / Dent Clin N Am 48 (2004) 183–202 Fig. From this size.19]. All information available about the anatomy of the canal system and the technical difficulty of the case should be taken into consideration. Glide path Before using any NiTi rotary instruments. which often means enlarging the canal wider than previously thought. . Straight line access on radiograph.192 H. In many cases such as ribbon-shaped canals. the apex should be enlarged at least three to four ISO sizes bigger.02 taper) needs to be created so that the fragile tips of small-sized NiTi rotary instruments can follow the path without exploring the canal or cutting. averages cannot apply in every case. instrument binding at the working length. Even light pressure or a small amount of torque would otherwise fracture these instrument tips. a glide path for these instruments up to ISO size 20 with stainless steel K hand files (0. A clinical judgment needs to be made to define the MAF size. 4. Dotted lines and arrows indicate areas of dentinal overhang to be removed. The ideal apical preparation would result in a consistently round form because this allows for better cleaning of the entire canal wall and better apical seal [18. clinicians should try to reach as close as possible to this goal whenever possible.

H. Apical preparation Apical preparation consists of four steps (apical pre-enlargement. S2 are ideal for this purpose. with an apical diameter of at least size 20. because different canals require different approaches. requiring cleaning the files after each pull. the taper is increased gradually deeper down into the canal. similar to the shape of the Eiffel Tower in Paris. the original apical canal diameter is larger than size 20. In very difficult cases. S1. ProTaper finishing instruments F1 to F3. France. In easy cases. apical enlargement. Body shaping The next step is a fast and effective removal of the coronal and middle canal third. They first shape the canal to a flared form with more taper coronally than apically. . Often. the more the clinician should decide to use passive instruments. 2) has been successfully used for this purpose in decreasing taper order in a crown down manner. and apical finishing) that are described in the following sections. NiTi rotary instruments also can be used by hand. Walsch / Dent Clin N Am 48 (2004) 183–202 193 A suitable hand instrumentation technique for stainless steel files smaller than size 15 is watch-winding and pull. apical LightSpeed preparation. provided that F3 reached the working length. The classic GT file set (see Fig. Apical pre-enlargement The idea of apical pre-enlargement is to cut quickly and effectively the apical canal third to a size to which the canal at working length can quickly and safely be enlarged. This technique is also considered a crown down approach: the taper is moved crown down. Only the apical 2 to 3 mm need to be further enlarged. Active instruments such as ProTaper can perform this step even more effectively. so the resulting canal form is flared. ProTaper plays a major role in this hybrid concept: a full sequence of these instruments can subsequently perform both body shaping and apical pre-enlargement with ease. The best technique for sizes 15 to 20 is the balanced force technique [20]. The ProTaper shaping instruments SX. This sequence can be repeated several times if necessary until working length is reached. this can be done with active instruments that cut aggressively. All four steps may not be necessary in each individual case. leaving a canal form that allows ideal access for the apical preparation. Then. will leave an ideal preparation form. for example. This instrument sequence will move the canal taper even further apically (crown down). The more difficult the case (the more severe the curvature or the smaller its radius).

71 0.42 0. Apical enlargement can be performed with active or passive tapered instruments.36 0.42 0.04 (4%). whereas a size 50 instrument with a 0.06 taper will cut along the 4 mm from the tip.46 0.57 — — — — — — 0. and 0.44 .02 (2%).71 0. Table 5 shows that a size 50 instrument with a 0.42 0.37 0.45 0.43 0. Provided that a ProTaper F3 instrument has reached the working length. Table 2 compares an instrument with a tip size of 35. The Table 3 Diameter comparison between the multi-tapered ProTaper F3 instrument and 3 consistently tapered nickel–titanium instruments with tapers of 2%.64 0.57 — — — — — — 0.30 0.41 0.52 0. 4%.39 0.41 0. the size prepared by ProTaper F3 is already size 39 (see Table 2). and 6% in size 40 Diameter of ProTaper F3 Diameter of consistently tapered NiTi instruments in size 40 Distance from tip (mm) (9%) (7%) (6%) (4%) (2%) 0 1 2 3 4 5 0. Table 4 with size 45.37 0.48 0.64 0. it becomes obvious that a size 35 instrument (regardless of the taper) used after a ProTaper F3 instrument to the same length in the canal only cuts at the very tip (up to less than 1 mm from the tip) because at 1 mm from the tip.04 taper will cut only at the apical 3 mm.40 0.39 0.06 (6%).38 0. depending on the difficulty of the canal curvature.39 0. it often needs to be enlarged more. based on the decision of which size MAF should be used for the individual canal.43 0.40 0.02 or 0. 0.48 0. and Table 5 with size 50. Walsch / Dent Clin N Am 48 (2004) 183–202 Table 2 Diameter comparison between the multi-tapered ProTaper F3 instrument and 3 consistently nickel–titanium instruments with tapers of 2%.40 0.36 0. 4%.41 0.42 0. Tables 2 through 5 show diameter comparisons at different levels from the tip of the multi-tapered ProTaper F3 instrument and other NiTi rotary instruments with consistent tapers of 0.35 0.43 0.47 0.39 Apical enlargement After pre-enlarging the apex safely.45 0. and 6% in size 35 Diameter of ProTaper F3 Diameter of consistently tapered NiTi instruments in size 35 Distance from tip (mm) (9%) (7%) (6%) (4%) (2%) 0 1 2 3 4 5 0.46 0. Areas in which the consistently tapered instruments are larger than the ProTaper F3 instrument are highlighted in gray.39 0.30 0. Table 3 with size 40.35 0.50 0.36 0.42 0.38 0.35 0.48 0.194 H.

49 0. but each instrument cuts only minimally and its cutting action is accomplished quickly after only one to three rotations.52 0. it is not difficult to enlarge the apex even wider because other NiTi rotary instruments like FlexMaster or other active or passive tapered instruments in sizes such as 40 with a 0.53 0.58 0. and therefore.55 .45 0.52 0.45 0.47 0.30 0. a size/ taper sequence in the following order can be used: 35/0.50 0.50 0. 45/0.04.56 0.71 0. minimal torque load.50 0.06. and 45/0. 4%. according to Table 4. This process can easily be done using the instruments by hand.04 taper and even size 50 with a 0.59 0.47 0.04.45 0.54 0.06 or 0.60 0. Walsch / Dent Clin N Am 48 (2004) 183–202 Table 4 Diameter comparison between the multi-tapered ProTaper F3 instrument and 3 consistently tapered nickel–titanium instruments with tapers of 2%.48 0.48 0.39 0.64 0.195 H. Provided in a clinical case that the desired MAF size is 45 and a 0.06.53 0.54 0.71 0.48 0. 35/0. and 6% in size 45 Diameter of ProTaper F3 Diameter of consistently tapered NiTi instruments in size 45 Distance from tip (mm) (9%) (7%) (6%) (4%) (2%) 0 1 2 3 4 5 0.50 0.52 0.06. and it is safer and faster than changing the files in a motorized handpiece.30 0.02 taper can be used subsequently with minimal coronal interference. then this corresponds to the apical widening concept. Table 5 Diameter comparison between the multi-tapered ProTaper F3 instrument and 3 consistently tapered nickel–titanium instruments with tapers of 2%.50 idea of this comparison becomes clear: after having reached the working length with a ProTaper F3 instrument. 4%.48 0.64 0. The number of instruments for this step of instrumentation seems large.49 0. and 6% in size 50 Diameter of ProTaper F3 Diameter of consistently tapered NiTi instruments in size 50 Distance from tip (mm) (9%) (7%) (6%) (4%) (2%) 0 1 2 3 4 5 0.46 0. 40/0. minimal cutting surface.56 0.56 0.57 — — — — — — 0. Accumulation of dentinal shavings at the apex is almost completely avoided.06 taper should be achieved.62 0.39 0.51 0.50 0.59 0.54 0.53 0. 40/0. To minimize the torque each instrument has to carry. If all instruments are used to working length.57 — — — — — — 0. only the apical 3 mm need to be enlarged.65 0.04.

The irrigation needle or the gutta percha cones might not be able to smoothly bypass these steps on the outer wall of the canal curvature. The instruments are all used to working length in increasing size order. a step back is needed to create a taper in the apical part of the canal. the severity of the curvature may not have allowed the use of the same instrument around the particular curvature without previous apical preenlargement as described earlier. At several millimeters from the working length.5 mm for each LightSpeed size will result in a 0. In some cases. leaves steps in the canal wall. Apical LightSpeed preparation This step is necessary when the desired MAF size is bigger than a size that can be prepared with tapered instruments in a curved canal [21].196 H. 5. The apex will be enlarged to the desired size starting with a LightSpeed instrument that is one LightSpeed size larger than the last instrument that previously reached the working length.025 taper. Step back increments of 0. Hybrid sequences overview. 1-mm increments will give a 0. and no instrument should be left out. Because the resulting apical canal form is cylindric. The form of this ‘‘pseudo-taper.05 taper. . Walsch / Dent Clin N Am 48 (2004) 183–202 Fig. the difference in size between the existing ProTaper preparation and the size of the instrument used for the apical enlargement becomes so big that this instrument can slightly straighten in the canal curvature and therefore does not need to be bent so hard to follow the curvature. The more severe the curvature.’’ however. the smaller the taper of the apical preparation should be and the more the clinician should decide to use passive instruments.

H. 5. The apical finish after LightSpeed step back can follow by hand with the LightSpeed MAF size or another passive instrument that can follow to working length without much effort. then it can be performed with LightSpeed. and in extremely difficult cases. Hybrid sequences overview The whole idea of the hybrid concept can be condensed to the overview shown in Fig. the cases become more difficult. and if the MAF size demands.04 taper and a size that follows to working length easily. The apical enlargement according to the difficulty of the case can be performed with active or passive instruments.02 or 0. The left side represents easy cases. See text for detail of the case. Walsch / Dent Clin N Am 48 (2004) 183–202 197 Fig. in most cases. This smoothes the steps in the outer wall of the curvature and merges the step back taper into the more coronally located taper. can be managed with ProTaper instruments. (A–C) Sample case 1. As new instruments are developed. with passive instruments. they can be integrated into this hybrid concept. Apical finishing Apical finishing can be performed using the LightSpeed MAF size instrument or another passive instrument in a 0. 6. Toward the right side. The body shaping and apical preenlargement. . The instrument will be forwarded to working length in a clockwise rotating or a watch-winding motion one or two times by hand.

ProFile instruments of size/taper 35/0. 4 to 1.04. Apical enlargement was done with Flexmaster instruments of size/taper 35/0.06. 6 through 10 show several clinical cases in ascending order of difficulty.06. 6). The mesial canals were completed with ProFile instruments of size/ taper 35/0. Walsch / Dent Clin N Am 48 (2004) 183–202 Fig. 40/0. and 55/0.198 H. and 45/0. In case 1 (Fig.04. Taper lock was avoided. Sample cases Figs.04.04.06. See text for detail of the case. 45/0. The protocols of instrumentation used for each case are described below.04.04 were used.06.04. The isthmus has been completely opened with ultrasonic instruments and Hedstro¨m hand instruments. Straight line and radicular access were performed with GG burs in descending order from 4 to 1. For the distal canals. Straight line and radicular access were performed with GG burs in the following order: 1 to 3. 40/0. 35/0. 8) was moderately curved. Case 3 (Fig.04. Body shaping and apical pre-enlargement were managed with ProTaper to F3. 7.04. and 40/0. Case 2 (Fig. Apical enlargement was performed with passive ProFile instruments. . Active instruments were used exclusively according to the low-grade difficulty of the case. 35/0. straight line and radicular access were performed with GG burs in descending order from 4 to 1. 40/0. 35/0. Instrumentation to ProTaper F3 completed body shaping and apical preenlargement. 40/0. having a mild curvature. (A–C) Sample case 2.04.06. 7) also had a mild curvature. 50/0.

and 20/0. After gaining access into the canal lumen with ultrasonic instruments. F3 went only 3 mm short of working length. mesial to size 60. Case 4 (Fig. A step back was performed: distal to size 70.06. Walsch / Dent Clin N Am 48 (2004) 183–202 199 Fig. step back to size 55.10. 9) represented a severe curvature. Then. Because of the degree of the mesial curvature. apical enlargement could not be performed with tapered instruments.08. LightSpeed was used to size 80. 20/0. (A–D) Sample case 3. 8.04 by hand.H. Apical enlargement was performed with a ProTaper F3 instrument by hand. straight line and radicular access were achieved with GG burs in the order of 1 to 3. ProTaper was used to F3 for body shaping and apical pre-enlargement. The apex was then enlarged to LightSpeed size 35. 4 to 1. Body shaping and apical pre-enlargement in the buccal canals was performed with ProTaper instruments to F2. . See text for detail of the case. After gaining access into the mesio-buccal canals with small hand instruments and GT files of size/ taper 20/0. and the canal was smoothed with LightSpeed size 80 by hand.06 was used by hand in a watch-winding motion to smooth the step back steps. A ProFile instrument of size/ taper 45/0. distal to size 55. Case 5 (Fig. LightSpeed instruments were used for this step: mesial to size 45. 10) had a very large and long palatal canal that was completely calcified coronally. which went passively. step back to size 90 and 100. straight line access and body shaping with GG burs size 5 to 3 was done to 4 mm short of working length. and the steps were smoothed with a ProFile instrument of size/taper 35/0. Therefore.

See text for detail of the case.02 taper or LightSpeed instruments should be used. 9. and only by hand. cannot be managed properly with tapered NiTi rotaries. Limitations of the hybrid concept Coronally located canal curvatures.200 H. . Walsch / Dent Clin N Am 48 (2004) 183–202 Fig. NiTi hand files used in a step back approach or the use of LightSpeed instruments seems to be the best option for such cases. (A–C) Sample case 4. particularly when there is a considerable canal length located apically of the curvature. Extremely severe curvatures (radius \2 mm) should not be followed with any engine-driven instruments. NiTi K hand files with 0.

like those often found in the mesial roots of mandibular molars. and instrumentation of the merging canal should be performed only to the merging point. hand instrumentation is recommended. NiTi rotary instruments used with a motor can deflect at uneven parts of the canal wall. 10. sometimes do not join at the apex but join more coronally. followed by recleaning the main canal to working length. One of the two canals will often reach from the orifice to the apex (main canal). and become jammed or separated. Merging canals. B) Sample case 5. In S-shaped curvatures. Ribbon-shaped canals are the classic case for circumferential filing by hand. Apical canal bifurcations often do not allow any straight instrument to follow into either branch of the furcation. engine-driven instruments should be used only to the point where the first curvature turns into the second one (where the curvature changes its direction).H. be pulled away from their paths. Walsch / Dent Clin N Am 48 (2004) 183–202 201 Fig. Beyond that level. C-shaped canals should only be hand instrumented because of their unpredictable anatomy. Different instruments of different NiTi rotary instrument systems and other . (A. the main canal should be identified and instrumented to working length. Pre-curving stainless steel files seems to be the best solution. Following the merging canal to working length means forcing the instrument through a kink. the merging point needs to be identified. Then. With small hand files and tactile sense. Summary Each individual case requires an individual instrumentation approach. whereas the other will meet the first one in a severe angle (merging canal). See text for detail of the case. Never pre-curve NiTi rotary instruments.

Roth A. Liu DT. [18] Luks S. [20] Roane JB. Tronstad L. Walsch / Dent Clin N Am 48 (2004) 183–202 instrument systems can be combined in a hybrid concept.11:203–11.3:24–9. Micallef JP. Wesselink PR. Bahcall JK. Calas P. Barkis D. Feldman MJ.. Sabala CL.35:264–9. Steiman HR. Effect of experience on quality of canal preparation with nickeltitanium files. J Endod 1998. J Endod 1977. [10] Weine FS. Microscopic investigation or root apexes. Dietz R. The balanced force concept for instrumentation in curved canals. Louis (MO): C. Tronstad L. The three wave concept of HERO 642. Shaping ability of LightSpeed rotary nickel-titanium instruments in simulated root canals. [17] Kerekes K. Duncanson MG. [2] Thomson SA.25:294.3:114–8. [19] Hwang HK. J Endod 1999.25:752–4.2:20–31. J Endod 1977. J Endod 1985. [13] Wu MK. [14] Kuttler Y. Guttapercha versus silver points in the practice of endodontics. Berlin: Quintessenz Verlags-GmbH. [15] Kerekes K. [5] Dietz DB. Hoen M. Lautenschlager EP. [8] Schilder H. Endodontic practice. basic and advanced topics. 1996. Intracanal treatment procedures. Borden BG.29: 113–7. based on an understanding of where each instrument performs its cutting action in the canal and when and how to use each instrument to its best ability. The accuracy of two clinical techniques to determine the size of the apical foramen [abstract]. 1st edition. Morphometric observations on the root canals of human molars. References [1] Knowles KL. [9] Moodnik RM. 1974. Philadelphia: Lea & Febinger Co. . Wurzelkanalaufbereitung mit Nickel-Titan-Instrumenten. Morphometric observations on the root canals of human premolars. Jou YT. Dummer PMH. Int Endod J 1999. Machtou P. Sealing ability of isthmuses by different obturation techniques [abstract].202 H. [3] Vulcain J.26:68–71. J Endod 1999.23:742–7. Int Endod J 1996. J Am Dent Assoc 1955. Kombinierte Technik. Di Fiore PM. St. [4] Gabel WP. Christiansen RK.88:714–8. J Endod 2000. [7] Blum JY.31:341–50. [12] Levin JA. Endod Pract 1999. [6] Baumann M. J Endod 1977. Jou YT. Location of contact areas on rotary ProFile instruments in relationship to the forces developed during mechanical preparation of extracted teeth. J Endod 1976.3:74–9.2:261–6. Effect of rotational speed on the breakage of nickel-titanium rotary files. Ibarrola JL.50:544–52. [16] Kerekes K. 5th edition. Oral Surg Oral Med Oral Pathol 1999. Assessing apical deformation and transportation following the use of LightSpeed root canal instruments. J Endod 1997. 2002. Effect of rotational speed on nickeltitanium file distortion. Mosby. Dorn SO. Dent Clin N Am 1974. 8th edition. Pink FE. Efficacy of biomechanical instrumentation: a scanning electron microscopic study. different hybrid instrumentation sequences can be used. [11] Grossman LI. Tronstad L.18:269–96.24:283.V. with some limitations. Depending on the desired MAF size and the difficulty of the case. Roris A. Kim S.32:108–14. [21] Hu¨lsmann M. N Y State Dent J 1965. Levey M. Cleaning and shaping the root canal. Part 2. Morphometric observations on the root canals of human anterior teeth. Does the first file to bind correspond to the diameter of the canal in the apical region? Int Endod J 2002.

This is best accomplished by using warm gutta percha. many clinicians made the transition to warm gutta percha. California) (Fig. this is a hybrid of several techniques discussed in various articles [1]. University of Pennsylvania. Often. Canals are commonly finished with a 0.see front matter Ó 2004 Elsevier Inc. Fenton. All rights reserved. Orange. Kratchman. This proper removal is accomplished by activating the System B coil with a finger while advancing the now-hot tip (the unit is set at 220 C) down the canal to within 4 to 5 mm E-mail address: sikratch@aol. Then. School of Dental Medicine. Several years ago.Dent Clin N Am 48 (2004) 203–215 Obturation of the root canal system Samuel I. Practitioners tend to develop a system that works best for them.1016/j. the transition in endodontics took place from stainless steel hand files to nickel–titanium rotary files. warm techniques due to the taper created in the canals. doi:10. 1).cden. with the System B heat transfer system (Sybron Endodontics. PA 19104-6030. After creating clean. taking twice as long as the newer.com 0011-8532/04/$ . 3). tapered canals.12. Missouri) (Fig. It must also be kept in mind while instrumenting that a size 40 to 45 rotary is necessary to go within 4 mm of the working length of each canal so that the medium System B tip will then be able to fit approximately 4 to 5 mm from the working length.04 taper rotary files instead. the new S-Kondensers (Obtura/Spartan. and the Obtura II (Obtura/Spartan) (Fig. The 0. 4). USA There have been numerous articles written on instrumentation techniques using the different rotary nickel–titanium files on the market. DMD Department of Endodontics.06 taper rotary file. This technique allows the proper removal of the bulk of gutta percha from the canal while transferring heat to the 4.06 taper most closely resembles the medium-sized tip on the System B. and if the preparation is finished with 0. 240 South 40th Street. This information is not relevant for this article other than when choosing the proper tip for the System B unit (Fig. 2).to 5-mm apical plug. and not only did the radiographic appearance improve but it was also more time efficient [2].2003. clinicians need to adequately obturate the root canal system. then the medium/fine System B tip would be indicated. Philadelphia. Obturation often was still performed with cold lateral condensation of gutta percha.004 .04 or 0.

they heat up almost instantaneously to the set temperature. Kratchman / Dent Clin N Am 48 (2004) 203–215 Fig. and then the tip is withdrawn from the canal with the now-severed gutta percha wrapped around the tip. 2. of the working length. After allowing the tip to cool for 10 seconds while still in the canal. .204 S. Nonstandardized medium gutta percha cones and a gutta gauge can be used to customize those master Fig. 1. it means there was not adequate tug back of the master cone and a new cone will need to be refitted [3]. Because the tips are hollow. System B unit from Sybron Endodontics. The finger is then removed from the coil and the System B tip is allowed to cool down. There will be a learning period when a clinician new to the technique pulls out the entire gutta percha cone from the canal instead of leaving behind that apical plug. When this happens.I. New set of three S-Kondensers (Obtura/Spartan). the coil is engaged for a split second while pushing apically.

The medium System B tip compares closely to a medium gutta percha cone and a 0. . 4.S. Kratchman / Dent Clin N Am 48 (2004) 203–215 205 Fig.I. Fig.06 taper rotary nickel–titanium file. The Obtura II unit comes complete with instructional video and plastic practice blocks. 3.

Gutta gauge. Because of the heat transfer process of the System B.06 taper created in the canals. Kratchman / Dent Clin N Am 48 (2004) 203–215 Fig. 5). 5. The next step is to .04 and 0. The medium gutta percha cones most closely resemble the 0. there is now a softened apical plug of gutta percha in the canal. used to customize the gutta percha cone.06 taper standardized gutta percha can now be purchased.I. but 0.206 S. cones (Fig.

The nickel titanium end is marked at 5 mm intervals (Fig. 6. which is easy to clean and maintains its color throughout autoclaving. Kratchman / Dent Clin N Am 48 (2004) 203–215 207 Fig. The handles are made of an anodized aluminum. The obturation phase of treatment has now become the easy part of a root canal [4]. The Obtura II has helped to improve the density of fills as well as increasing efficiency. Apical plug of gutta percha remains in canal and can now be packed down. The . The handles are notched to provide a finger rest. and has a . 9).S.02 taper which gives you excellent compressive strength without compromising flexibility. This is where the new S-Kondensers from Obtura/Spartan come in handy.stainless steel. so that the black is size 40nickel titanium on one end and size 80.stainless steel. The S-Kondensers have improved on several problems that existed with other condensers. 6). and the blue S-Kondenser is 60-nickel titanium and 120. They are ISO standard colors.stainless steel on the other end. to better gauge when you have reached the desired apical distance. positioned so that you can grip the S-Kondenser comfortably and apply firm pressure during condensation (Fig.I. 8). The yellow S-Kondenser is 50-nickel titanium and 100. After down packing the apical plug of gutta percha we are ready for the Obtura II to back fill each canal (Fig. condense this plug of gutta percha. 7). achieving a better seal apically (Fig.

you screw the tip into place with the wrench and use the bending tool to place it between a 45-60 degree curve on the tip (Figs. Indentation in handle of S-Kondenser for finger rest during condensation. . 7. 10 and 11). whether you are obturating a lower tooth or an upper tooth. without it loosening too much that gutta Fig. Obtura II unit is nicely packaged with an instructional video and a plastic block with which to practice. Now place the wrench back over the tip and quarter turn counter-clockwise. The tips come in 23 gauge and a thinner 25 gauge.208 S. you must use the gutta percha pellets designed for this tip.I. If you choose to use the 25-gauge tip. Notches at 5-mm intervals on the nickel–titanium end of the S-Kondensers. There is a little trick to installing the Obtura II tip that will allow you to obturate either maxillary or mandibular teeth without changing the tip. First. This will allow you to rotate the tip. 8. Kratchman / Dent Clin N Am 48 (2004) 203–215 Fig. loosening the tip slightly. which soften at a lower temperature.

209 .I. Kratchman / Dent Clin N Am 48 (2004) 203–215 Fig. 10.S. Obtura II unit ready to go. Installation of needle. 9. Fig.

Kratchman / Dent Clin N Am 48 (2004) 203–215 Fig. 11.210 S. Tip-bending instrument. Fig. . 12.I. Void in gutta percha filing.

If one is not happy with the appearance of the final x-ray. Most so-called problems with obturation are actually problems with one’s instrumentation. If you hear a crackling noise while injecting the gutta percha. This will prevent voids from occurring between the apical gutta percha and the remainder of the filling (Fig. The obturation is in essence an ‘‘impression’’ of what the canal looks like after it has been instrumented. 13). backpack with the stainless steel end of the S-Kondenser. as long as you continue to press the trigger. 12). Gutta percha extruding through apex. not segmentally. re-heating that apical plug. you must go back with a file to make sure there is no debris in the canal and that the flaring is adequate. you are actually criticizing the instrumentation/flaring of the canals.S. The root canal is now complete. let it remain there for three seconds. and after completing the back filling of each canal. You may back fill in one motion.I. 13. you must Fig. Kratchman / Dent Clin N Am 48 (2004) 203–215 211 percha would extrude out the sides. You must place the Obtura II tip in the canal and make contact with the apical plug of gutta percha before back filling. filling the canal. If the master gutta percha cone does not seat all the way to the desired working length. it is an air pocket. If the master cone goes beyond the apex (Fig. and will not affect the fill. Once the tip is in contact with the now cooled apical gutta percha plug. .

(A) Preoperative radiograph of retreatment of maxillary first molar. and instead of burning out the gutta percha with the System B to within 4-5 mm of the working length. 14. making room to place the second master cone to the desired length.212 S.I. 14). and the entire canal is back-filled in one motion with the Obtura II. attempt to achieve an apical stop with further instrumentation at a shorter working length. Oregon) (B) Postoperative radiograph. but also toward the side of the apex. This case could not have been obturated using a cold lateral gutta percha technique. Kratchman / Dent Clin N Am 48 (2004) 203–215 Fig. There are some cases where the aforementioned technique of obturation makes an impossible case approachable. That second master cone is then burned out to within 4-5 mm. Examine the pre-operative x-ray of a rnaxillary molar with previous root canal therapy (Fig. due to an . Portland. This maxillary molar had an apical bifurcation of its palatal canal. (Courtesy Kevin Edwards. DDS. this time we went down to within 2mm of the working length. Note that the periapical lesion associated with the palatal root is not only at the radiographic apex.

Fig. (A) Preoperative radiograph of mandibular bicuspid with trifurcation of canals. DDS. 15. Kratchman / Dent Clin N Am 48 (2004) 203–215 213 Fig.I. Portland. Four-canal maxillary molar.S. Oregon) (B) Postoperative radiograph. (Courtesy Kevin Edwards. . 16.

Fig.Fig. 17. (A.B) Mandibular molars with lateral canals filled in apical third of distal root. . Maxillary molar with long but gentle curvature of MB root. 18.

Three separate master cones were used. Kimbrough WF.I. and with the warm vertical technique using a thermoplasticized (semi-solid) form of gutta percha. Practitioners often develop their own ‘‘hybrid’’ technique. depict the results obtainable with the above described obturation technique. J Endodon 1997. 18) have small lateral canals in the apical third. allowing room for the next master cone to be seated. 15). Kim S. There are many approaches to solving a problem. with the hope that others may incorporate some aspects into their own style. These two mandibular molars (Fig.1:7–18.S. . [3] Weller RN. [4] Buchanan LS. Dent Clin N Am 1967. References [1] Guess G. Edwards K’ Yang ML.29:509–12. Another case where the warm vertical technique was necessary was a mandibular bicuspid with a trifurcation of its canal (Fig. Analysis of continuous S-Kondensers wave obturaton using a single-cone and hybrid technique. The purpose of this chapter was to share a technique of obturation. Similarly. Continuous wave of condensation technique. A comparison of thermoplastic obturation techniques: adaptation to the canal walls.23:703–6. the whole system was back filled with the Obtura II. Anderson RW. Filling root canals in three dimensions. in endodontics. Iqbal M. J Endodon 2003. A few more cases such as this maxillary molar with four canals (Fig. there are several ways to instrument and to obturate the root canals. After the three master cones were placed and the System B used to leave three apical plugs of gutta percha.1:723–44. 17). using ideas from several colleagues. Kratchman / Dent Clin N Am 48 (2004) 203–215 215 inability to properly seat two master cones side by side in the palatal canal. 16) and another maxillary molar with a long gentle curve (Fig. [2] Schilder H. Endodon Pract 1998. with each cone being burned out apically to the trifurcation. you will see a higher incidence of filling such lateral canals.

2003. PA 19104-6030.see front matter Ó 2004 Elsevier Inc. Technically speaking. University of Pennsylvania. a good access cavity requires the removal of the coronal interferences to insert the endodontic instrument in a straight line path to the apical third. it would also weaken the root walls and possibly predispose the root to lateral or strip perforations and root fractures during post placement [6].1016/j. most obturation techniques require the placement of the obturation instruments (spreader or plugger) in the apical or middle third of the root to manage the delicate area [7]. In fact. the preparation of the root canal system is crucially important not only for the removal of the organic and inorganic irritants but also for allowing the correct placement of the obturation material. Thus.Dent Clin N Am 48 (2004) 217–264 MicroSeal systems and modified technique Francesco Maggiore. extend as close as possible to the cementodentinal junction. providing a hermetic apical and coronal seal.005 . Also. The extension of the access cavity has to be a balance between access that is large enough to allow the location of all the canal orifices but conservative enough to prevent any unnecessary loss of coronal dentin. Nevertheless. Although additional removal of coronal dentin during the access preparation would facilitate ample access. School of Dental Medicine. doi:10. USA Proper obturation of the root canal system is an essential final step of endodontic therapy.11.com 0011-8532/04/$ . in situations in which E-mail address: fmaggiore@hotmail.cden. the aforementioned objectives can be obtained by an endodontic filling that is able to penetrate the entire root canal system. and eventually obliterating within the obturation material any remnants or debris that the endodontic instruments or solvents are not able to eliminate [1–3]. A key step during the biomechanical instrumentation and for the obturation is the access cavity preparation. Philadelphia. 240 South 40th Street.5]. All rights reserved. Thus. the endodontic filling has the primary goals of keeping clean the environment achieved by the biomechanical instrumentation. The concept that a successful obturation depends very much on proper cleaning and shaping procedures is well accepted by practitioners. DDS Department of Endodontics. and have an adequate density necessary for the operator to radiographically evaluate the endodontic procedure [4.

Fig. 3. Orange. California). 25/0. MicroSeal engine spreaders (size/taper): 25/0. It is obvious that this enlargement is not biologically dictated. it is due to the technical limitation of the obturation method. 1. Orange. . it is often necessary to enlarge the coronal or middle third of the root canal to allow the placement of the instrument to the proper depth [8].02 (bottom) (SybronEndo). a conservative preparation.218 F. or a curved canal. One of the obturation techniques more likely suitable for the above cases is the MicroSeal obturation system (SybronEndo.04 (top). Components of the MicroSeal system (SybronEndo. rather. California) Fig.02 (top). 25/0.02 (middle). 25/0. Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig.02 (middle). MicroSeal finger spreaders (size/taper): 20/0.04 (bottom) (SybronEndo). 20/0. this placement is not possible because of a canal’s narrow dimension. 2.

Maggiore / Dent Clin N Am 48 (2004) 217–264 219 Fig.F. 0. 4. 5. Fig. MicroSeal condenser size 25. Measurement of the angle between the blades and the axis of the instrument (SybronEndo). 0.04 taper (SybronEndo). MicroSeal condenser size 25.04 taper. .

6. Fig.02 (middle right). 7. MicroSeal gutta percha cones (size/taper): 25/0.02 (far left) (SybronEndo). Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig. . 25/0.02 (middle left).04 (far right). Vertical and lateral forces generated by the MicroSeal condenser (SybronEndo). 35/0. 30/ 0.220 F.

. Description of the system The MicroSeal technique was introduced in 1996 and can be considered one of the thermomechanical compaction techniques that uses a rotary instrument to plasticize the gutta percha and move it within the root canal apically and laterally. the NiTi condenser. the gutta percha syringe.F. MicroSeal nickel–titanium finger and engine spreader The MicroSeal system provides finger and engine NiTi spreaders. different aspects of this technique are discussed. The MicroSeal technique suggests the use of one master cone at the working length. 8. 30 and in 0.04 taper in size 25 (Fig. 25. and a special formulation of gutta percha available in cones or in cartridges. The first thermomechanical compaction technique was introduced by Dr. 1979).02 taper in size 20. In this article. the spreader compacts the gutta percha cone in the apical third and because of its high flexibility. MicroSeal gutta percha heater (SybronEndo). The MicroSeal system consists of a series of instruments: the nickel– titanium (NiTi) spreader. J. 1). After placement of the master cone at the working length. They are designed to be used with a continuous rotational motion. The finger spreaders are available in 0. 3).T. respectively (Fig. The engine spreaders are mounted on a 1:16 reduction handpiece and used at 300 rpm (Fig. it can reach the proper depth in the majority of the clinical situations [9]. because it is able to preserve a conservative preparation and provide an adequate penetration by the obturation instruments in the apical third. 2). McSpadden in 1979 (personal communication. the gutta percha heater. called low-fusing gutta percha or ultra–low-fusing gutta percha. Maggiore / Dent Clin N Am 48 (2004) 217–264 221 Fig.

9. The condenser is .222 F. SybronEndo). Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig.04 taper in size 25. and is available in 0. MicroSeal condenser Particularly interesting is the MicroSeal condenser (Fig. 4). Radiograph confirming the length of the master cone (MicroSeal. has a reverse helix design.02 taper in sizes 25 to 60 and in 0. This instrument is made of NiTi.

Also. . the condenser creates centrifuge forces able to press the warm gutta percha Fig. MicroSeal condenser coated with warm gutta percha from the cartridge (SybronEndo).F. 10. designed to be used on a 1:1 electric handpiece between 5000 and 7000 rpm. the condenser has the primary goal of generating heat by friction to plasticize the gutta percha cone. 11. During its rotation into the root canal. Maggiore / Dent Clin N Am 48 (2004) 217–264 223 Fig. MicroSeal spreader reaches the proper length alongside of the master cone (SybronEndo).

MicroSeal condenser carries warm gutta percha into the canal (SybronEndo). Because it is made of NiTi. Tooth No. 12. Apical hook in the distal root. 19. On careful inspection of the angle between the reverse blades of the condenser and the axis of the instrument. Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig. a decrease in amplitude from Fig.224 F. into all the spaces within the root canal. it is highly flexible and can reach the apical 2 to 3 mm in most cases. 13. .

that is. provided an angle varying from 60 to 30 (Fig. Maggiore / Dent Clin N Am 48 (2004) 217–264 225 Fig. for these reasons. 14. 5). Note the small access cavity to preserve the prosthetic preparation and the management of the apical bifurcation. This assessment has a very important clinical implication.F. 23 showing an apical bifurcation. The tooth has been prosthetically prepared before the root canal. the handle to the tip can be noticed. 6). generating vertical and lateral forces selectively (Fig. This unique design is most likely thought to prevent the possibility of extrusion of the gutta percha beyond the apical constriction. the angle between the blade and the shaft is more open in the coronal part and gradually becomes more closed in the apical part. the condenser can be considered to act as a plugger in the coronal part of the root canal and as a spreader in the apical region. 23. The author’s measurements. Also. the forces generated by the rotating condenser are directed apically mostly in the coronal part of the instrument and laterally at the tip level. (A) Preoperative radiograph for tooth No. In fact. using Cad-Cam software. . (B) Postoperative radiograph for tooth No.

the MicroSeal technique requires the use of one master cone at the working length. The MicroSeal gutta percha cones are made of low-fusing gutta percha. Depending on the temperature.226 F. advertised to be alpha (a) gutta percha at room temperature.02 taper in sizes 25 to 60 and in 0. 7). 14 (continued ) MicroSeal gutta percha cones According to the manufacturer. Warming of the b-phase gutta percha will change the crystalline structure into the aphase gutta percha characterized by low molecular weight due to the .04 taper in size 25 (Fig. Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig. The b-phase gutta percha is the commonly found gutta percha at room temperature and consists of a high molecular weight polymer. MicroSeal gutta percha cones are available in 0. gutta percha is available in two different crystalline forms: the beta (b) phase (37 ) and the alpha (a) phase (42 –44 ).

15. Fig. cooling of the aphase gutta percha will produce b-phase gutta percha. and shrinkage occurs during this process.F. . Apical foramen with oval shape. Maggiore / Dent Clin N Am 48 (2004) 217–264 227 Fig. breakage of the chemical links of the polymer. Spreader D11T (top). Conversely. it has been suggested to compact the material while it is cooling with the use of a plugger [10]. Therefore. 16. spreader D11 (bottom). to compensate for the undesirable shrinkage of the gutta percha for obturation methods using warm gutta percha.

228 F. the gutta percha cartridges consist of ultra–lowfusing gutta percha. only minimal shrinkage takes place during the cooling phase. For infection control purposes. Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig. . For the same reason. the gutta percha cartridges are made for single-patient use only. In the MicroSeal system. Use of accessory cones to create an apical stop for canals with oval foramen. the cones are made of a-phase gutta percha at room temperature. 17. In this way.

Maggiore / Dent Clin N Am 48 (2004) 217–264 229 Fig. Gutta percha cones tested in the preclinical study: Hygenic. . and MicroSeal ( far right). and MicroSeal.02 taper from the following brands: Hygenic ( far left). Caulk Densply ISO color (middle left). 0. Caulk Densply ISO noncolor (middle right). 19.F. Caulk Densply ISO color. 18. Fig. Radiographic comparison of gutta percha cones size 30. Caulk Densply ISO noncolor.

20. . Radiographic comparison of gutta percha cones size 30. Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig.02 taper from Caulk Densply ISO noncolor (left) and MicroSeal (right).230 F. 0.

It is advisable to confirm the length of the master cone radiographically (Fig. the selection of the master cone is the first step of the procedure. 8).02 taper is indicated for narrow canals.F. it is ready to be used. 9). MicroSeal gutta percha heater To warm the gutta percha in the cartridge. the MicroSeal heater can be used (Fig. Gutta percha cones from Caulk Densply ISO noncolor used in the preclinical test.5 to 1 mm short of the working length is the criteria for the selection of the master cone. . Description of the technique When the canal is ready to be filled. the working temperature is reached within 45 seconds. As soon as the gutta percha in the cartridge becomes plasticized. According to the manufacturer. 21. large canals require a 0. Proper tug back 0. Maggiore / Dent Clin N Am 48 (2004) 217–264 231 Fig. This machine is very easy to handle and after the heater is turned on. whereas the 0.04 taper master cone.

and 7 mm (E) levels. The coated condenser can now be introduced into the canal space created by the spreader (Fig. 12). The NiTi MicroSeal spreader is advanced to within 1 to 2 mm from the working length and is rotated (Fig. it is introduced into the canal. Radiographs in clinical (A) and proximal (B) view. 5 mm (D). 11). . 22. n ¼ 8. the gutta percha cartridge is heated and the condenser is introduced into the cartridge and gently removed to cover 5 to 6 mm of the instrument with warm gutta percha (Fig. Cross-sections at the 1 mm (C). After dipping the tip of the selected master cone into endodontic sealer. Group 1. space has been created between the master cone and the canal walls.232 F. 10). Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig. Next. The spreader is then removed from the canal.

02 taper condenser when a 0.02 taper master cone has been used and to select a 0. This force has to be countered by firmly keeping . it is advisable to select a 0.04 taper condenser when a 0. It is important to place the condenser as close as possible to the working length and not to rotate the instrument while inserting. In the very first moment of the spin. After it is seated. 22 (continued ) Generally. Maggiore / Dent Clin N Am 48 (2004) 217–264 233 Fig.04 taper master cone has been used. the rotation of the condenser can begin.F. the generated force promotes a tendency to withdraw the condenser from the canal. The selection of the condenser strictly depends on the clinical situation.

22 (continued ) .234 F. Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig.

11]. in certain clinical circumstances. Maggiore / Dent Clin N Am 48 (2004) 217–264 235 Fig. then the condenser can be coated with new gutta percha and a second spin can carry additional gutta percha into the canal. especially in the case of curved canals. To improve some of the aspects of the technique. Alternately. 22 (continued ) the instrument in place for 1 or 2 seconds. the following suggestions are made by the author. 13). because it guaranties that the instrument reaches the proper depth of 1 mm from the working length [9. 14) that require management by a prebent spreader. If the first spin does not fill the canal completely. as with a sharp apical hook (Fig. the use of the NiTi spreader is of great advantage. . The whole procedure requires no more then 6 seconds.F. the NiTi spreader can be bent under pressure and may not transmit its compacting force to the gutta percha cone. Modifications The technique just described is the one recommended by the manufacturer. The condenser is then removed while rotating with a gentle stroking motion against the canal walls. First. there are root canal anatomies such as apical bifurcations (Fig. Also.

Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig. Thus. 23. and the NiTi spreader cannot be precurved [12]. the author finds the use of . 15).236 F. In addition to the apical compaction of the master cone. the use of the stainless steel spreader D11T can replace the NiTi finger spreader for the apical compaction of the master cone where indicated (Fig. Radiographs in clinical (A) and proximal (B) view. 4 mm (D). Cross-sections at the 1 mm (C). and 5 mm (E) levels. Group 2. n = 2.

Because there is a high variation in size and shape of the apical anatomy. For this purpose. there are situations in which the master cone alone does not .F. Maggiore / Dent Clin N Am 48 (2004) 217–264 237 Fig. the use of the master cone has the primary objective of creating an apical stop. further use of the condenser coated with warm gutta percha is prevented from pushing any filling material beyond the apical constriction. 15). the D11 spreader is not supposed to reach the apical area because its main action occurs at the orifice level. specifically in the coronal part of the canal (see Fig. the subsequent introduction of the condenser becomes easier and faster. It is very important that the spreader D11 is not forced but is gently guided as far as it will go into the root canal. In this way. In this way. Second. 23 (continued ) a more tapered spreader such as the D11 helpful to create more space.

02 taper. 16) or is ribbon shaped due to the confluence of two canals in the same apical exit [13]. . size 25) may provide a more secure apical stop against which the rotating condenser can be safely pushed (Fig. the use of one or two accessory cones (generally 0. In fact. in addition to the master cone. In these situations. the apical foramen is oval in shape (Fig. In such situations. Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig. the use of one master cone in all cases could result in some undesired overfilling or underfilling. 17). 23 (continued ) completely seal the apex.238 F.

Maggiore / Dent Clin N Am 48 (2004) 217–264 239 Fig.04 taper gutta percha cones are available only in size 25—with the obvious limitation that this represents—the author would like to emphasize how important it is to have a good tug back in the apical 1 mm of the canal. A less tapered cone . the selected master cone can be a 0. Other than the fact that the 0. according to the manufacturer.F.02 taper.04 taper or a 0. 23 (continued ) Third.

Also. A fourth consideration is the use of the plugger at the end of each compaction.04 taper master cone would risk creating a bulk of gutta percha at the orifice level. but it is also true that after the .02 taper master cone is the one more likely indicated in the majority of the cases. Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig.240 F. Thus. the 0. the selection of a 0. It is true that the ultra–low-flow gutta percha from the MicroSeal system undergoes less shrinkage. 23 (continued ) can achieve this result more predictably. if one considers that the use of one or two accessory cones in addition to the master cone is frequently indicated. This bulk would interfere with further insertion of the condenser coated with warm gutta percha.

2 mm (D). and 6. the use of the plugger is of great benefit. Maggiore / Dent Clin N Am 48 (2004) 217–264 241 Fig. To better adapt the melted filling material to the canal walls. 5 mm (F). Radiographs in clinical (A) and proximal (B) view. 6 mm (G). use of the condenser. The author believes that the obturation does not end with the rotation of the condenser.5 mm (H) levels. 24. the coronal compaction using .F. an amorphous mass of gutta percha fills the canal. n = 1. Cross-sections at the 1 mm (C). Group 3. 4 mm (E).

prevents formation of voids. The MicroSeal gutta percha cones appear to be less radiopaque (Fig. Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig.242 F. Fifth. which may present a disadvantage because the evaluation of the root canal filling is clinically done on the basis of its radiographic density [4]. . The author compared the radiopacity of the MicroSeal gutta percha cone with other gutta percha cones on the market. one of the main differences between the MicroSeal gutta percha cones and other brands of gutta percha cones is the radiopacity. 24 (continued ) a plugger of proper size greatly increases the adaptation of the gutta percha to the root canal system. 18). and ultimately provides a more dense and homogeneous obturation.

Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig. 24 (continued ) 243 .F.

24 (continued ) A preclinical test was done to explore the possibility of using a more radiopaque brand of gutta percha cones for the MicroSeal technique and for using one or two accessory cones and a plugger. the author decided to use the MicroSeal gutta percha cones and the Caulk Densply (ISO noncolor) gutta percha cones in the preclinical test (Fig. an interesting observation was that the ISO color and the ISO noncolor gutta percha cones by Caulk Densply. Gutta percha cones (Hygenic. 20). Therefore. Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig. Caulk Densply ISO color. 21). the cones manufactured by Caulk Densply (ISO noncolor) were the most similar to the MicroSeal cones in handling and obturation characteristics. In a preliminary stage of the study on extracted teeth. Caulk Densply International Standards Organization [ISO] noncolor. Among the different brands. In the preclinical study. . They also showed a higher radiographic density (Fig. different brands of gutta percha cones were substituted for the MicroSeal cones using the MicroSeal technique. and MicroSeal) were tested (Fig. showed a very different clinical behavior. 19).244 F. despite having the same manufacturer.

and 5 mm (E) levels. Radiographs in clinical (A) and proximal (B) view. All canals were instrumented using the same instrumentation . Group 3. 25.F. n ¼ 6. 3 mm (D). Cross-sections at the 1 mm (C). Maggiore / Dent Clin N Am 48 (2004) 217–264 245 Fig. with each group consisting of two narrow canals and two large canals. Preclinical test Sixteen straight single-rooted teeth were divided into four groups of 4 teeth each.

3. 25 (continued ) technique. alternating after each instrument. Canals were prepared up to size 35 or 45 depending on the initial apical size and were irrigated with sodium hypochlorite and EDTA.06 taper. The canals were prepared using the Profiles 0.246 F. Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig. After access was made. the preflaring was accomplished using Gates–Glidden instruments in sizes 2. For the . and 4.

F. 25 (continued ) 247 . Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig.

248

F. Maggiore / Dent Clin N Am 48 (2004) 217–264

Fig. 25 (continued )

obturations, the gutta percha cones were dipped in Grossman sealer in all
cases.
In group 1, the canals were obturated using one MicroSeal gutta
percha master cone, and no plugger was used after the condenser
rotation.
In group 2, the canals were obturated using one MicroSeal master cone
plus one or two accessory MicroSeal cones of 0.02 taper and size 25; the
plugger was used consistently after the condenser rotation.
In group 3, the canals were obturated using one master cone
manufactured by Caulk-Densply. No plugger was used after the condenser
rotation.
In group 4, the canals were obturated using one master cone plus
one or two accessory cones of 0.02 taper and size 25 manufactured by
Caulk-Densply, and the plugger was used consistently after the condenser
rotation.
After all the samples were prepared, they were sectioned at increments of
1 mm using a sectioning saw (Beuhler LTD, Lake Bluff, Illinois) under cool

F. Maggiore / Dent Clin N Am 48 (2004) 217–264

249

Fig. 26. Group 4, sample n = 6. Radiographs in clinical (A) and proximal (B) view. Crosssections at the 1 mm (C), 3 mm (D), 5 mm (E), and 7 mm (F) levels.

water. The sections were then stained with methylene blue and examined
under the operation microscope at 20 magnification.
Each sample was evaluated regarding the (1) adaptation of the gutta
percha to the canal walls, (2) presence of voids in the obturation, (3)

250

F. Maggiore / Dent Clin N Am 48 (2004) 217–264

Fig. 26 (continued )

radiographic density, and (4) ability of the gutta percha to fill irregularities
and lateral canals.
Each category was scored as poor, acceptable, good, or very good. Three
different operators carefully analyzed the results of the study.
In group 1, opposite results were observed. In fact, the cross-sections of
narrow canals (ie, lower anterior teeth) showed a satisfying adaptation of
the gutta percha to the canal walls, and the filling material looked
homogeneous for the full length of the canal. The cross-sections of large
canals (ie, canines and lower bicuspids), however, showed voids in the
obturation material and poor adaptation to the dentinal walls in some of
the samples. The radiographic density was generally evaluated as poor
(Fig. 22).

F. Maggiore / Dent Clin N Am 48 (2004) 217–264

251

Fig. 26 (continued )

In group 2, regardless of the canal size, the adaptation of the gutta percha
to the canal walls was generally good. Voids were not observed in any of the
samples. Flowing of the gutta percha in lateral canals was observed in some
of the sections. The radiographic density was also evaluated as poor in this
group (Fig. 23).
In group 3, the adaptation of the gutta percha was considered good in
narrow canals and inconsistent in most of the large canals. The crosssections documented an unusual anastomosis in a lower anterior partially
filled with gutta percha (Fig. 24). The radiographic density was considered
satisfactory (Fig. 25).
In group 4, the adaptation of the filling material to the canal walls was
consistently good or very good, both in narrow and large canals. The filling
material was homogeneous and able to flow into the intricacies of the root
canal system and to adapt to different types of anatomy. The radiographic
appearance showed good contrast and was considered superior compared
with the other groups (Fig. 26).

252

F. Maggiore / Dent Clin N Am 48 (2004) 217–264

Fig. 26 (continued )

The following conclusions were made: 
The MicroSeal technique, with or without the use of the plugger, gave
good results in narrow canals with MicroSeal and Caulk-Densply gutta
percha cones using one master cone or using accessory cones. The
radiographic appearance of the MicroSeal cone obturations, however,
had less contrast compared with the obturations done with the CaulkDensply cones. 
In large canals, the MicroSeal technique resulted in inadequate wall
adaptation when one master cone alone was placed and no plugger was
used. In these cases, the use of accessory cones and a plugger is advised. 
The use of one or two accessory cones improved the obturation only for
large canals. 
Technically, there was no difference in the handling of the MicroSeal or
Caulk-Densply gutta percha.

F. Maggiore / Dent Clin N Am 48 (2004) 217–264

253

Fig. 26 (continued ) 

The MicroSeal technique using MicroSeal or Caulk-Densply gutta
percha cones proved very effective for obturating lateral canals and
irregularities.

Discussion
From this study, it appears that from the technical point of view,
there is no difference between the use of the MicroSeal and the use of

. is introduced into the canal. They melt at the same rpm of the condenser after the instrument. Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig. coated with warm gutta percha. The only difference appears to be the slightly better radiopacity of the Caulk-Dentsply cones compared with the MicroSeal cones. provide gutta percha that is homogeneously integrated with the MicroSeal gutta percha from the cartridge.254 F. The cones. 26 (continued ) Caulk-Densply gutta percha cones. when melted.

In fact. SH Baek. Maggiore / Dent Clin N Am 48 (2004) 217–264 255 Fig. MicroSeal condenser undergoing very high torsional stress before reaching the breaking point (SybronEndo).F. 28. the Hygenic cones and the Caulk Densply ISO color cones seemed to be more elastic and required a higher speed and more time for the condenser to start the Fig. 27. (Courtesy of Dr.) . Cross-section showing a fragment of MicroSeal condenser incorporated into the filling material. The cones from Hygenic and from Caulk Densply (ISO color) had very different behavior compared with the MicroSeal and Caulk Densply ISO noncolor cones in this preclinical study. South Korea.

256

F. Maggiore / Dent Clin N Am 48 (2004) 217–264

Fig. 29. Tooth No. 32. (A) Preoperative radiograph. (B) Postoperative radiograph.

melting process. Also, it seemed that the gutta percha from these brands
(after melting) did not integrate homogeneously with the MicroSeal gutta
percha from the cartridge and, therefore, provided an unpredictable
obturation.
These observations are only clinical. Further research is needed to
investigate the molecular and physical properties of the MicroSeal gutta
percha cones compared with other brands.
The author’s clinical observations suggest that the benefit of accessory
cones really depends on the size of the canal and its apical shape. Lower

F. Maggiore / Dent Clin N Am 48 (2004) 217–264

257

Fig. 30. Tooth No. 19 showing 90 apical curve. (A) Preoperative radiograph. (B)
Postoperative radiograph.

258

F. Maggiore / Dent Clin N Am 48 (2004) 217–264

Fig. 31. Tooth No. 31 with C-shaped canal. (A) Preoperative radiograph. (B) Postoperative
radiograph.

Fig. 32. Tooth No. 32 with severe canal curvature. (A) Preoperative radiograph. (B) Working
length radiograph. (C) Postoperative radiograph.

260

F. Maggiore / Dent Clin N Am 48 (2004) 217–264

Fig. 32 (continued )

anterior teeth with narrow canals did not seem to benefit from the use
of accessory cones. Narrow canals were adequately obturated by the use
of one master cone without accessory cones. Alternately, upper or lower
canines or bicuspid with large canals showed a better obturation when
accessory cones were used compared with canals in which only one master
cone was used. These teeth also showed a dense obturation in the apical
third and in the rest of the canal, especially where isthmuses or irregularities
were present.
Using a plugger after the condenser seemed to be associated with a more
homogeneous obturation and better adaptation to the canal walls. Also, the
use of the plugger seemed to reduce the formation of voids within the gutta
percha filling.
The technique, using MicroSeal or Caulk-Densply ISO noncolor gutta
percha cones, seemed to be associated with the filling of lateral canals,
irregularities, isthmuses, and anastomoses in a high number of cases. In fact,
cross-sections from 12 of 16 specimens showed obturation material flowing
into the intricacies of the root canal system.
According to the preclinical test and the author’s clinical experience, it is
important to point out that the inappropriate use of the condenser may

F. Maggiore / Dent Clin N Am 48 (2004) 217–264

261

Fig. 33. Tooth No. 14 exhibiting apical bifurcation. (A) Preoperative radiograph. (B)
Radiograph after the first obturation showing five canals and filling material between the
two palatal canals. (C) Working length determination of the sixth canal. (D) Postoperative
radiograph showing six separate canals and six separate foramina.

result in instrument separation. This separation may occur at greater speeds
than the one suggested by the manufacturer. Also, situations whereby the
condenser is roughly forced behind a canal curvature or the condenser is
pushed against a ledge on the canal wall may lead to failure. Even if these
situations predispose the MicroSeal condenser to fracturing, the author
emphasizes that because the instrument is made of superelastic NiTi alloy, it
requires significant stress to reach the breaking point (Fig. 27). When the
fracture occurs, it appears that the instrument separates at the last 2 mm and
the fragment is incorporated into the gutta percha (Fig. 28).
Despite the high variety of clinical situations in which the MicroSeal
technique is recommended, the clinical scenario at which the technique
seems to reach its limit is represented by those cases in which it is not
possible to create an apical stop. For example, immature teeth with open

262 F. 29 through 33 were performed using Caulk-Densply ISO noncolor gutta percha master and accessory cones. Clinical cases The clinical cases presented in Figs. . the MicroSeal technique together with the modifications discussed in this article may be a very important tool in the hands of the endodontist. Maggiore / Dent Clin N Am 48 (2004) 217–264 Fig. In conclusion. 33 (continued ) apices or retreated teeth with seriously damaged apical foramina may represent a risk too high because of the lack of apical control and the possibility of gutta percha extrusion. Knowledge of the technique’s indications and limitations represent an important step in the learning curve for those practitioners who are willing to incorporate a new obturation method into their clinical techniques.

33 (continued ) .Fig.

5:298. p. Dumsha TC. Maggiore / Dent Clin N Am 48 (2004) 217–264 References [1] Naidorf IJ. In: Gutmann JL. Sundqvist G. radiographic and histologic perspectives on success and failure in endodontics. The influence of the method of canal preparation on the quality of apical and coronal obturation. J Endod 1979.67:458. p.36:379. Dent Clin N Am 1974. The diagnostic reliability of the buccal radiograph after root canal filling. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1974. Louis (MO): Mosby. J Prosthet Dent 1992. In: Cohen S. Weber CR. editors. Volumetric and densitometric comparison between nickel titanium and stainless steel condensation. 7th edition.37:954. 123–55. [6] Gutmann JL. Aldrich W. Lovdahl PE. Loushine RJ. Problem solving in endodontics. Int Endod J 1987. Schilder H. Hagglund B. Glickman GN. Oral Surg 1984. Appropriateness of care and quality assurance guidelines. Primack PD. J Endod 1990.22:195. Burns RC. [12] Gutmann JL. 3rd edition. 258–361. The history and molecular structure of gutta-percha. J Endod 1996. St Louis (MO): Mosby. Walton RE. [7] Allison DA. [2] Sjogren U. [11] Speier MB. II.16:498. [13] Vertucci FJ.264 F.58:589. . Hovland EJ.21:221. Thoden van Velzen SK. Hovland EJ.18:329–44. [5] Kersten HW. 1994. Factors affecting the long-term results of endodontic treatment. Dent Clin N Am 1992. Clinical microbiology in endodontics. [9] Berry KA. [4] American Association of Endodontists. [10] Goodman A. St. Witherspoon DE. The dentin-root complex: anatomic and biologic considerations in restoring endodontically treated teeth. [8] Gutmann JL. Clinical. 1998. [3] Gutmann JL. Obturation of the cleaned and shaped root canal system. Problems in root canal obturation. editors. Nickel-titanium versus stainless steel finger spreaders in curved canals. Chicago: American Association of Endodontists. The thermomechanical properties of gutta-percha. 1997. Wing K. J Endod 1995. Pathways of the pulp.20:20. Wesselink PR. Root canal anatomy of the human permanent teeth.

5 million endodontic cases were treated in 1960 [1]. 500 Spruce Street #204. San Francisco. USA b Private Practice. San Francisco Endodontics. the need for performing conventional root canal therapy also has increased dramatically. In accordance with the studies mentioned above [1–6]. a 10% failure rate would result in the failure of at least 2. CA 94118. All rights reserved. These advancements. the need to maintain a patient’s dentition for a longer period of time has led to a barrage of advanced procedures that were nonexistent years ago. 2155 Webster Street. MSa. DDS. A survey performed by the American Dental Association stated that approximately 2. The ‘‘bad news’’ is that tens of millions of endodontically treated teeth are failing each year for a variety of reasons [5.4 million cases. Current studies estimate that the number of endodontic cases treated annually ranges from 24 to 50 million [1–4]. * Private Practice. For example.Dent Clin N Am 48 (2004) 265–289 Conventional endodontic failure and retreatment Ralan Wong. This is a dramatic increase. this still leaves a failure rate of 10% to 15%.10. School of Dentistry.* a Department of Endodontics. The ‘‘good news’’ is that hundreds of millions of teeth are salvaged through the combination of endodontics.002 . the success rate for conventional-treated teeth is 85% to 90%. San Francisco Endodontics. periodontics. in conjunction with increased dental patient education and awareness. the future of endodontics will include dealing with the retreatment of its failures. have helped to promote the view that the dentition should remain throughout people’s lives.com 0011-8532/04/$ . Therefore.2003. CA 94115.b. As a result.1016/j. E-mail address: witewong@hotmail. 500 Spruce Street #204. doi:10. Ruddle [5] described this vast increase in endodontics as the ‘‘good news– bad news’’ dilemma.see front matter Ó 2004 Elsevier Inc. San Francisco. USA Technologic advancements in dentistry have vastly improved the quality of care provided to the general population. CA 94118. San Francisco. As the life span of the population increases.cden.6]. University of the Pacific. and restorative dentistry.

and subjective interpretation of the results. Throughout the literature. however. quality of the obturation. case Table 1 Potential factors influencing success of endodontic therapy Factors Effect or success No effect on success Presence of apical pathosis Extension of filling material Tooth type Observation period Maxilla versus mandible Obturation quality Coronal leakage Missed canals Adequate cleaning and shaping Pulp vitality Culture Obturation technique Type of filling used Number of treatments Postoperative restoration Intracanal medicament Preoperative pain Postoperative pain Apical resorption Length of time for treatment Procedural periapical inoculation Patient’s health Age Gender Operator skill Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes These criteria are presented in order of decreasing frequency at which time they were investigated to correlate with endodontic failures. method of determining failures. There are some factors. these factors have been evaluated and reviewed with both agreement and disagreement as to their influence on endodontic success rates. number of cases evaluated. [7–31]. patient’s subjective response to and compliance with treatment. These factors are as follows: the extension of the filling material. tooth selection. operator’s ability. that consistently are reported to have an influence on success or failure. Some important factors are the frequency of recall evaluations. There have been many articles published [7–31] that provide a range of success anywhere from 53% to 95%.266 R. Wong / Dent Clin N Am 48 (2004) 265–289 Factors for failures Not all conventional root canal treatments are successful. Data from Refs. There are approximately 25 potential factors reported in the literature that influence the outcome of conventional endodontic therapy (Table 1) [27]. . Several aspects can be attributed to the way in which endodontic successes and failures are reported. There are many reasons for the wide variety of outcomes.

restorability. The decision to perform nonsurgical conventional retreatment. inadequacy of cleaning and shaping.8]. coronal leakage. bacteria.16. and exceptional restorative techniques. type of filling material. through technologic advancements. Conversely. or even extraction and placement of an implant must be assessed carefully. These techniques and procedures are still limited by the amount of pulp tissue. Presently. Therefore. the belief is that the most important cause of failure is recontamination of the entire root canal system resulting from coronal bacterial leakage [26. conventional retreatment can have a positive effect on the prognosis. Consultation with the appropriate specialist. or team of specialists. Fig.R. prognosis. microsurgical endodontics. and iatrogenic procedural errors must be dealt with. can be considered a success. improved training. presence of periapical pathosis. a permanent restoration usually has been placed. iatrogenic procedural errors. a diligent examination of the suspected tooth must be performed to gather information so that the proper treatment can be rendered. iatrogenic procedural errors. quality and extent of the obturation. Moreover. patients’ desires. ability of the operator. nor does age or gender appear to play a role in the pathogenesis of endodontic failures. even if surgery ultimately becomes necessary. and any other irritants that can be removed successfully [5]. and cost effectiveness must be considered before treatment planning. the prognosis for retreatment is much poorer than that for routine conventional endodontics. missed canals. For example. to determine feasibility of treatment. ability to gain access to the filling material and the terminus of the root canal system. fractures. There have been considerable improvements in endodontic microsurgery techniques that allow for the once-hopeless tooth to be salvaged [5.6. Endodontic retreatment: case selection Conventional endodontic retreatments are different from routine endodontic therapy in that the tooth already has been treated without success. Conventional retreatment versus microsugery Endodontic failures are associated most often with periapical pathosis and pain. clinicians can obtain successful superior results. yet is .6. A tooth that exhibits an incomplete obturation to the terminus of the root. and cost effectiveness is of utmost importance for the clinician. Wong / Dent Clin N Am 48 (2004) 265–289 267 selection. No correlation of the maxilla versus the mandible exists. however. Furthermore. Certain teeth that have demonstrated clinical inadequacies in previous endodontic treatment. root canal system anatomy. 1 depicts a brief rationale strategy for deciding whether conventional nonsurgical retreatment or endodontic microsurgery is the best option. and length of the observation period [5.33–35].32].

or healing of periapical pathosis.268 R. In addition. The history of the previous endodontic treatment can allow the clinician to discern what treatment was rendered and why. (From Friedman S.) clinically sound. potential problems with further treatments can be anticipated if the endodontic . Films that were taken preoperatively and postoperatively can demonstrate presence. Considerations for retreatment of an endodontically treated tooth. Stabholz A. Wong / Dent Clin N Am 48 (2004) 265–289 Fig. 1. with permission. Factors that affect root canal failures can be attained from previous radiographs.12:28. Endodontic retreatment–case selection and technique. absence. is a case in point. This type of tooth can be monitored rather than retreated unless the tooth in question is to receive a new definitive restoration or recurrent caries are present. Part 1: criteria for case selection. J Endod 1986.

there are always unforeseen circumstances that are out of any clinician’s control that may account for the compromised treatment. shaping. such as pain and swelling. or if a treatment was already performed and symptoms continue to arise. Wong / Dent Clin N Am 48 (2004) 265–289 269 treatment was performed on a tooth that presented with an abscess. The presence of acute intense symptoms. Restorations of poor quality. and obturation of the entire root canal system must be evaluated carefully depending on who the previous operator was. Adequate cleaning and shaping procedures differ based on the . and three-dimensional obturation of the root canal system. The anatomy and morphology of the root canal system significantly affects the outcome of routine conventional endodontic therapy. The treatment itself also can be in question. as well as the quality of the endodontic treatment. Often. The quality of cleaning. The time lapse between the previous treatment and the postoperative symptoms is of utmost importance to the diagnosis. then retreatment or microsurgery must be considered high on the list of treatment alternatives. are more amenable to conventional retreatment [32. must be evaluated to meet the present-day criterion. brokendown teeth must be evaluated for restorative needs and crown-lengthening procedures to allow for a ferrule effect and a healthy biologic width [5].38]. When there are severe periodontal pockets with noted presence of radiographic endodontic pathosis. Subsequently. 2) [36]. is the driving force for most patients seeking to be evaluated and treated. as well as the strategic positioning of the tooth. The root canal system creates an intricate array of anastamosis and bi. When the presence of severe periodontal disease or recurrent caries creates an unfavorable crown-to-root ratio. If the tooth in question is needed to support a fixed prosthesis that was newly fabricated. as well as the growing restorative needs for the patient. which communicate with the surrounding periodontal apparatus. The state of the previous treatment must be scrutinized. Nevertheless. untreated root canal systems can harbor necrotic debris and bacteria that permeates through to adjacent periradicular tissues and ultimately promotes pathosis [6]. The prior endodontic treatment also must be evaluated for adequate cleaning. Untreated canals. A clinical examination of subjective and objective signs will allow the clinician to determine the nature of the problem. the need for extraction or retreatment must be investigated for the correlation for the endodontic–periodontic lesions or a vertical fracture (Fig. shaping. however. resulting in several portals of exit [37. Thus. lacking marginal integrity.R. then extraction is the only option.and trifurcations. or with recurrent caries must be replaced. Prescribing antibiotics and performing an incision and drainage can provide useful relief before committing to a treatment plan. Therefore. a good periodontal assessment will help the clinician to determine the restorability and type of restoration for each tooth.39]. consultation and discussion with the previous operator will provide invaluable information about the prior treatment and proposed retreatment. Anatomic and morphologic differences.

270 R. Wong / Dent Clin N Am 48 (2004) 265–289 .

Therefore. removal of the extended gutta-percha results in the disarticulation of the extruded guttapercha mass and may require surgical intervention. Finally. and perforations contribute to the inability to retreat the system successfully. all restorations of poor quality. clinicians typically access through the restoration if it is intact and deemed to be functional. As a result of trying to keep costs to the patient at a minimum. and iatrogenic procedural errors may result in endodontic microsurgery. influences of time. when making the decision to retreat or perform microsurgery. Wong / Dent Clin N Am 48 (2004) 265–289 271 training and experience of the clinician. calcifications. the clinician—whether general practitioner or specialist—must evaluate each case and assess the operator’s capability for treatment or referral accordingly. canals with severe curvatures. However. 2. Many retreatment cases are restored with a post. the cooperativeness of the patient must be considered. the obturated gutta-percha sometimes can be retrieved through the root canal system and removed from the periapical tissues.R. Furthermore. however. the decision to remove the coronal restoration is due primarily to the requirement of additional access to facilitate the retreatment process. or possible extraction. After all the data has been considered and discussed. Satisfactory and esthetic restorations are expensive and should be considered as a service to the patient. The apical extent of the obturation is always well defined. Retained coronal restorations also facilitate rubber dam placement. and crown. Removal of the coronal restoration in conjunction with the surgical operation microscope allows for enhanced b Fig. The removal of coronal restorations sometimes is unnecessary and contraindicated. Iatrogenic procedural errors such as transportations. Occasionally. Endodontically. The ability of the operator also must be evaluated. (D) Examination with microscope and capillary tip to locate vertical fracture. all alternative treatment plans and the overall prognosis must be discussed before treatment. This is extremely important because several retreatment techniques require training and experience and should not be attempted otherwise. Overextension of gutta-percha occurs when there is no apical seal of the root canal system [16]. Therefore. . ledges. expectations. poor marginal adaptation. and allow for easier temporization. and financial obligations.C) Initial examination with probing depths. prevent leakage. (B. ledges. dilacerations. and those that present with recurrent caries should be removed completely to facilitate the retreatment process [29]. core. the patient then can make an informed decision about retreatment. separated instruments. When this occurs. Gaining access to the root canal system Establishing access to the treated root canal usually is difficult. The clinician also must be aware of the patient’s desires. microsurgery. (A) Preoperative radiograph of abscess in tooth before treatment.

Wong / Dent Clin N Am 48 (2004) 265–289 assessment of tooth morphology. Special instruments have been designed to facilitate the removal of posts [5. Thin diamond burs and piezoelectric ultrasonics can assist with the final removal of the core around the post. It is kept in intimate contact in a counterclockwise fashion to facilitate loosening and Fig. untreated root canal systems. 3. Once straight-line access to the pulp chamber is created. studies agree that the retention of the post should be reduced first with the use of piezoelectric ultrasonics before its removal [5. the remaining core material is removed from the post. and enhanced access for the clinician also can be obtained. The literature provides evidence that a post space can cause a vertical root fracture. Facilitated post removal Access for endodontic retreatment cases usually includes removal of a post and core. Hewlett. due to weakening of the integrity of the canal wall [40–42].20. all core materials that are in contact with the post and with the pulp chamber must be removed. Roto-Pro bur (Ellman International.41. However. New York) The Roto-Pro bur is a six-sided. The use of ultrasonics alone can be sufficient to remove several posts. removal of a prefabricated or cast post can cause root fractures. . Ultrasonic vibrations can be used to disintegrate the cement and trough around the post to help with the loosening and removal. well-fitted.44]. Therefore. Therefore. and the coronal extent of silver cones can be detected.272 R.43–48]. The risk increases with long.43. Vertical fractures also may be identified easier once the restoration is removed. noncutting instrument that comes in two shapes: the regular straight tip bur and the football-rounded bur. larger-diameter posts [29]. before retrieval of the post. The bur is placed in a high-speed handpiece and rotates along the side of the post. radiographic information such as the identification of perforations. Cast post and cores should be reduced to a single post preparation before removal. Use of ultrasonic device to reduce cement and retention of cast post. Furthermore. Another instrument that allows for increased vibrations is the rotosonic.16.

(A) Preoperative radiograph with clinical crown and post broken at the gingival margin. Occasionally the post can break and cause obstructions in the canal.20. Also. California) are equipped with trephine burs that allow for the milling of the coronal 1 mm to 3 mm of the post itself.44]. 3) [5]. which results in unforeseen complications [20.R. Orange. (D) Postoperative radiograph. (Courtesy of Dr.) removal of any post (Fig. and have corresponding-sized tubular taps. (C) Placement of extraction pliers. These devices are the Gonon Post Puller.43. devices have been made to add forces along the long axis of the tooth to enhance post removal [5. irrigating. Therefore. 4.44]. Therefore. the use of piezoelectric ultrasonics without the use of a coolant such as water resulted in a bony dehiscence. caution must be observed when using either of these instruments. the Ruddle Post Removal System. it is recommended that the use of ultrasonics or rotosonics be used in conjunction with a constant. Wong / Dent Clin N Am 48 (2004) 265–289 273 Fig. (B) Placement of tubular taps. and the Masserann Kit. Rubber cushions are placed on the taps before mechanical threading of the . William Goon. sonic vibration may not be enough to retrieve posts from the root canal system. In a preliminary study at the University of the Pacific School of Dentistry [49]. and coolant such as water. However. The Gonon Post Puller and Ruddle Post Removal System (SybronEndo.

The post then can be removed with a counterclockwise motion (Fig. As a result. one size larger than the post should be selected. 4 (continued ) post. Wong / Dent Clin N Am 48 (2004) 265–289 Fig. The taps are screwed with a counterclockwise motion onto the post until a snug fit is obtained. The post removal pliers are placed with the extracting jaws engaged into the tap and on top of the rubber cushion for support. Afterward. It is used with a slow-speech latch attachment to screw into the post. while the screw is turned to open the jaws of the pliers. a trephine bur one size smaller than the post is selected. causing a build-up of pressure. The rubber cushions then are pushed down onto the functional biting surface of the tooth. 5). and loosen the cement. the Masserann Kit also has an extractor that makes use of . The Masserann Kit also uses a trephine bur. The instrument is held firmly. use the vibrations. The clinician should monitor the cushion on the tooth and either pause a few seconds or place an ultrasonic on the tap. The bur should be placed around the post instead of on the post [20. The combination will allow for future turning of the screw and eventual removal of the post coaxial to the root (Fig. 4).44]. the screw is difficult to turn. however.274 R. In addition. This larger trephine bur removes excess dentin supporting the post for approximately 3 mm into the orifice of the canal wall.

Considerations for the removal of gutta percha depend on the initial . Wong / Dent Clin N Am 48 (2004) 265–289 275 Fig. The disadvantage of the Masserann Kit is the initial unwarranted removal of excess dentin from around the post. Semisolid material removal Removal of gutta-percha can be obtained with several techniques.R. 4 (continued ) a mechanical device to grasp the post. Gaining access to the apical terminus The aspect of gaining patency to the apical foramen is arduous. The canals must be negotiated through removal or bypassing obstructions and filling materials in the canals. as mentioned above [5. Sometimes a clinician can encounter disarticulated instruments as well.6]. Ultrasonic vibration also can aid in the retrieval of the post. Obturated canals are filled mostly with either semisolid materials such as gutta-percha. and cements or with solid materials such as silver points and Thermafil obturators. pastes.

276 R. Switzerland) also are quite effective in the removal of the coronal portion of the filling material. when the canal is well condensed. 4 (continued ) examination and the quality and extent of the filling material. The fastest way to retreat a canal is to pull out the gutta-percha [29]. Glendora. Wong / Dent Clin N Am 48 (2004) 265–289 Fig. This is especially true when the canal is not condensed well [16].. Recent studies [50–54] have demonstrated the successful use of nickel-titanium rotary files as well. The quality of the obturation must be identified. Using any type of forceps or a Hedstrom file can remove the filling material immediately. Once the coronal portion of the filling material has been removed. . Removal of the coronal portion of the gutta-percha can be achieved with heat caries such as the TouchN-Heat (Kerr Corp. However. California) or System B (Analytic Endodontics. Orange. Table 2 summarizes considerations with regard to the elimination of gutta-percha in the canal. Gates Glidden burs (Dentsply Maillefer. the extent of the filling material and the canal curvatures must be noted. Before the use of these techniques. Ballaigues. California). it may necessitate the use of other instruments and techniques to facilitate removal. other techniques and devices then can be employed readily.

Sequentially larger K-type files then are inserted into the canal until all the gutta-percha mass is removed.) Solvents have been used in the past to soften and dissolve gutta-percha [16. It also is relatively inexpensive and easy to use. and 20 stainless steel file. . after which all solvents should be discontinued. and (8) white pine oil. The sequential technique involves refilling of the created reservoir in the canal orifice with drops of chloroform and picking into the dissolving guttapercha while filing with a size 10.R. due its effectiveness of dissolution [55.57.57]. However. all solvents are somewhat toxic to patients and should be used with caution [55.58]. (A) Preoperative radiograph of separated post in lower incisor. (C) Postoperative radiograph of post removed. (6) turpentine oil. This is continued until the terminus is negotiated. (B) Depth of trephination and use of Masserann Kit. 15. (3) xylene. (4) methylechloroform. William Goon. (7) pine needle oil. (Courtesy of Dr. (5) halothane. Chloroform is the most commonly used solvent. Solvents available for dissolution of guttapercha filling material are as follows: (1) chloroform.55–58]. chloroform and small K-type files are best suited. (2) eucalyptol. When small. Wong / Dent Clin N Am 48 (2004) 265–289 277 Fig. underprepared and curved canals need negotiation. 5.

the use of stainless steel hand files. with and without the use of solvents.59]. Nevertheless. Eucalyptol. 5 (continued ) Researchers have reported that the newer nickel-titanium rotary instruments can facilitate the removal of gutta-percha in the canal [50–54]. the use of the surgical operation microscope has been documented to improve the entire removal of gutta-percha from the canal walls (Fig. Chloroform unfortunately is classified as a beta-2 carcinogen [55. has proved to be more effective in complete removal of the filling material from the canal wall [50.278 R. an alternative.52–54. however. resulting in complications of the retreatment. 6) [59]. is less irritating than is Table 2 Considerations for gutta-percha removal Condensation Shape of canal Length Pull out Dissolve Poor Straight Overextended Well Curved Incomplete . Caution should be taken when using rotary files around curvatures and underprepared canals.57]. Moreover. Wong / Dent Clin N Am 48 (2004) 265–289 Fig. because disarticulation can occur.

however.R. and the Pacific Rim pose complications due to the hardness of the material [5]. It is. Wong / Dent Clin N Am 48 (2004) 265–289 279 Fig.61]. one must commonly deal with ledges. Disintegration of the coronal portion of the paste or cement can be enhanced with piezoelectric ultrasonic vibrations [5.57]. The use of ultrasonic vibrations will allow for . The extent of the filling material is again of the utmost importance.6. transportations. a lesseffective gutta-percha solvent and must be heated to improve the solubility of the gutta-percha mass. and calcifications. Pastes and cements can be grouped into categories of soft and hard setting as well as impenetrable and irremovable [5]. 5 (continued ) chloroform and has an antibacterial effect [55. Eastern Europe. leaving the middle and apical portion of the canal free of obstruction. Usually the coronal portion of the canal is obturated with the paste or cement. The geographic location at which the endodontic therapy was performed can aid in the decision of the retreatment.60. whereas pastes and cements that are used in the United States are usually soft and can be removed readily [5]. Use of a microscope also will facilitate removal of the filling material in the straight portion of the canal. Pastes that often are found in root canals performed in Russia. However.

the hardest of materials to be removed [5. although dangerous. but is limited in its usefulness. Tennessee) also can be helpful to soften the formidable material [5]. 6. and localization of the second mesial canal with the aid of the microscope. Memphis. Caution must be exercised with the amount of heat generated from the sonics. The use of end-cutting nickel-titanium rotary instruments such as the Quantec file (SybronEndo. Silver points can be removed with relative ease due to the chronic leakage that occurs and the loss of an apical seal with the cement . Heat has some effect on soft porous materials. (B) Postoperative radiograph of root canal fully treated after removal of the silver point gutta-percha. Solid materials removal The treatment plan for the removal of solid objects that obstruct the root canal system depends on the feasibility of removing or bypassing the impediment. can be helpful in penetrating the filling material and facilitate its removal. Gates Glidden burs also are useful with soft material. The end-cutting files.280 R. Orange. California) can be advantageous (Fig. 7).6. whereas the ‘‘E’’ is used for eugenol-based materials. (A) Preoperative radiograph of incomplete failing root canal. but do not afford great credibility with hard pastes and cements. and irrigating coolant must be engaged.61]. The ‘‘R’’ is used for resin-based materials. Wong / Dent Clin N Am 48 (2004) 265–289 Fig. Solvents such as Endosolv ‘‘R’’ and ‘‘E’’ (Endoco.

The extent of the obturation is significant. Long Island. Steiglitz forceps (Chige. Rather then pull along the long axis of the canal. Wong / Dent Clin N Am 48 (2004) 265–289 281 Fig. Before beginning any removal technique. Overextended points have a higher affinity for disarticulation into the periapical tissues and may require surgery. After exposing the silver point. However. over time. The quality and the diameter of the silver point must be considered when retrieval techniques are employed.R. The Quantec file and ultrasonics were used to remove the paste fill. New York). the clinician should manipulate the forceps with . The area of the flared preparation is advantageous for the removal of the silver point by the clinician [5]. Thin points have a tendency to dislodge with ease and can break more easily. the operator also must note that silver points are brittle and can fracture easily. 7. (A) Preoperative radiograph of an abscessed molar with a paste fill. Luckily. most canal preparations have a coronal portion of the canal that is flared whereas the silver cone is parallel in shape. (B) Postoperative radiograph revealing second mesial buccal canal. or a hemostat can be used to grasp the object. whereas larger diameter silver points have an affinity for the canal wall and can be more difficult to bypass and remove. a microscope should be used to ensure that all core build-up material and excess cements around the silver point are removed. a microneedled forceps. The operator should test the resistance of the silver point in the canal with a controlled tug on the forceps.

as well as the positive rake angles of the instrument. 8. (C) Use of the twisted Hedstrom technique. (D) Radiograph of silver point retrieval. Too often.16. then the use of ultrasonics on the forceps for an indirect vibration can help to loosen the point and remove the obstruction. A cotton roll is then positioned for . The operator must increase the size of the canal until it is possible to bypass the impediment with Hedstrom files on two to three sides. A radiograph should be exposed once the terminus has been negotiated.27. sequential enlargement of the canal wall is obtained.16. and should be avoided [5.27]. a fulcrum to elevate the silver point out of the canal.45]. will make it easier to grasp the obstruction from the canal [5]. Use of smalldiameter 08 and 10 files along with a chelating agent will assist in the task. Placement of ultrasonics directly on a silver cone will disintegrate the material. If the silver point has tension and resistance. Wong / Dent Clin N Am 48 (2004) 265–289 Fig. the operator will pull straight upward to mimic a post removal and the silver cone disarticulates into the canal. (B) Radiograph of one silver point separated in the apical third. Twisting the handles. the object must be located with an exposed radiograph and bypassed with K-type files. When the obstructed silver point fractures. (E) Postoperative radiograph. Upon negotiation of the apical foramen. resulting in unforeseen complications [5.282 R. A hemostat can be used to grasp the file handle. (A) Preoperative radiograph of a root canal failure with silver points.

California) can be used . Another radiograph is exposed to ensure that the obstructed filling material was removed (Fig. then extracting devices such as the post removal systems or the Endo Extractor Kit (Kerr Corp. Wong / Dent Clin N Am 48 (2004) 265–289 283 Fig. Glendale.. 8). 8 (continued ) leverage and the hemostat is rotated over it to remove the silver point. When an object cannot be bypassed or the silver point demonstrates a larger diameter.R.

8 (continued ) .Fig.

Wong / Dent Clin N Am 48 (2004) 265–289 285 Fig. unfortunately. Oklahoma) are either metal or plastic carriers of gutta-percha. 9. which. (A) Preoperative radiograph of failing endodontic treatment with Thermafil. Tulsa. Silver points are soft and can erode with mechanical manipulation from trephine burs. The trephine bur removes approximately 3 mm of surrounding dentin. The manufacturer has since changed the carrier to plastic. The rake angles also will present a problem with retrieval as they can engage the dentinal wall [5]. The coronal portion of the canal and obturator should be accessed using the post-removal techniques described above. After the adhesives are set.R. Therefore. choosing the exact trephine is extremely important. The metal obturator has cutting flutes that entangle the surrounding gutta-percha and make it more difficult to retrieve and remove the obstacle [62]. a metal obturator will present itself as the original obturation material. [43]. ultrasonic vibration can ensure the removal of the obstruction. The metal obturator can be . (B) Successful retreatment of the case using indirect ultrasonic vibration to remove the metal cores. An extractor with adhesive in the cannula is selected and placed over the object. is more difficult to remove. Occasionally. Thermafil obturators (Dentsply. Tulsa Dental. The Endo Extractor Kit has four trephine burs that correlate to files with different diameter sizes. in a few number of cases. the extractor is checked for resistance. Carrier-based obturators originally were designed with metal carriers [62]. as discussed earlier. The use of cyanoacrylate adhesives aids in the adhesion of the silver point to the extractor.

Rule DC. and the endodontic patient encounter forms. These advancements allow clinicians to gain insight into the retreatment of failing root canals.30(12):94. the use of heat will melt the plastic. Direct or indirect use of ultrasonics can loosen the metal carrier from the canal wall and gutta-percha. In: Cohen S. St. Non surgical endodontic retreatment. [3] ADA Survey Center. Chicago: American Dental Association. Louis: Mosby-Year Book. Once the carrier is loosened. Survey of dental services rendered from 1999. Burns RC. 2000. Plastic obturators. 2002. Survey of dental services rendered from 1990. Microendodontic nonsurgical retreatment. [4] Endodontic trends reflect changes in care provided. will erode with the use of ultrasonic vibration. Solvents can be used to remove coronal guttapercha and bypassing with hand files can loosen the obstruction for both the metal and plastic carriers [5. Newton CW. [2] AAE Survey Center. Dent Clin North Am 1997. 9). Wong / Dent Clin N Am 48 (2004) 265–289 grasped with a forceps similar to the silver cone removal technique mentioned above. References [1] ADA Survey Center. and patience. [7] Adenubi JO. 1995. to facilitate removal as well (Fig. survey of endodontists. The heated files penetrate the plastic and. after they cool. [5] Ruddle CJ. like silver points. Dental Products Report 1996. Br Dent J 1976. Chicago: American Dental Association. Furthermore. Pathways of the pulp. practice. . Survey of endodontic practice. Due to training. applying heat to the metal framework can dissolve the gutta-percha. Success rate for root fillings in young patients: a retrospective analysis of treated cases. clinicians can expand their capabilities alongside of these technologic advancements to perform endodontic retreatments with increased success.41(3):429. editors. March 1999. By emplying the fulcrum and leverage technique. Brown CE. the plastic—which becomes welded to the files—can be removed with ease using the fulcrum technique and forceps. Another technique uses heated Hedstrom files and insertion directly into the plastic carrier. removal with twisted Hedstrom files can be accomplished.64]. 8th edition. Chicago: American Dental Association.15:261. 2000. In addition. The clinician places two to three Hedstrom files into the core of the carrier and waits for them to cool. Nickel-titanium rotary instruments can also be used in the removal of plastic carrier-based systems. [8] Allen RK. creating further difficulties in retrieval of the obstacle. Upon removal of the carrier and gutta-percha.141:237.286 R. [6] Ruddle CJ. routine conventional retreatment can ensue. Summary Technologic advancements in dentistry and specifically endodontics have vastly improved the quality of care rendered to patients. The plastic obturator can be removed forcefully without removal of the gutta-percha mass surrounding it. the file can be removed readily [63]. J Endod 1989. A statistical analysis of surgical and nonsurgical endodontics retreatment cases.

9:198.30:533.17:368. A radiographic evaluation of the periapical status of teeth treated by the gutta percha-Eucha percha endodontic method: a one year follow up study of 458 root canals. et al. Rohlin M.86:366.R. [20] Morse DR.26:321.27(1):23.12:146.55:607. [17] Jokinen MA. [22] Petterson K.24(9):587.5:83. Swed Dent J 2003.12:68. Endodontic failures marked by lack of there-dimensional seal.18:527. [21] Pekruhn RB. [18] Lin LM. Seltzer S.70:65. Turkenkopf S. Ung B. In vitro bacterial penetration of coronally unsealed endodontically treated teeth. [33] Alves J. Drake D. et al. Roentgenologic and clinical evaluation of endodontically treated teeth. Long-term results of endodontic treatment performed with a standardized technique. J Can Dent Assoc 1969. Wong / Dent Clin N Am 48 (2004) 265–289 287 [9] Barbakow FH. Golber F. [19] Kerekes K. Knutsson K. Turkenkopff W. The dependence of the results of pulp therapy on certain factors: an analytic study based on radiographic and clinical follow-up examination. To culture or not to culture? Oral Surg 1964. Friedman S. Br Dent J 1970. J Endod 1990. J Endod 1979. J Endod 1983. Int Endod J 1998. Pulpal periapical disease: diagnosis and healing: a clinical endodontic study. Gaengler P. Petersson K. J Am Dent Assoc 1963. Endodontic failures and retreatment. [30] Swartz DB. Walton R. Clinical and radiographic study of pulpectomy and root canal therapy. Cleaton-Jones P. [25] Setlzer S. Evolution of the success of endodontically treated teeth. Reit C.126:566. [26] Smith CS. Endod Dent Traumatol 1989. Oral Surg 1970. Int Endod J 1993. [16] Ingle JI. editors. Bender IB. Harty FJ. [14] Harty FJ. 1985. Hansson L. In: Cohen S. Endod Rep 1987. Oral Surg 1974. An evaluation of 566 cases of root canal therapy in general dental practice. Factors influencing the success of conventional root canal therapy—a five year retrospective study. [32] West JD. Skidmore AE.37:271. [15] Heling B. Burns RC. Ramse A. The incidence of failure following single-visit endodontic therapy. [34] Torabinejad M. 6th edition. Factors affecting successful repair after root canal therapy. Setchel DJ. St. [23] Rawskii AA. Correlation of the positive culture to the prognosis of endodontically treated teeth: a clinical study. J Am Dent Assoc 1963. The major factors that influence endodontic retreatment decisions. Endodontics. Postoperative observations. Ingle JI. Factors associated with endodontic failures. J Endod 1992. Shepard LI.66:9.67:651. [11] Frajich SR. [28] Storms JL. Parkins BJ. Skribner JE. [10] Bender IT.6:485. The prognosis of pulp and root canal therapy: clinical and radiographic follow up examinations. Friedman D.18:625. Fall/Winter: 9–12. 31(5):354. [29] Strindberg LZ. Tronstad L. [13] Grossman LI. J Endod 1980. Scand Dent Res 1978.35:83. 14(Suppl 21). Wengraf AM. Pathways of the pulp. Louis: Mosby-Year Book. Coronal leakage: endotoxin penetration from mixed bacterial communities through obturated. 3rd edition. Success rate in root canal therapy: a retrospective study of conventional cases. Acta Odontol Scand 1956. [24] Selden HS. Twenty years of endodontic success and failure. 1994. Pearson LA. Cantarini C. Griffin JA. Odontol Rev 1961. post-prepared root canals. Philadelphia: Lea and Febiger. [27] Stabholtz A. [31] Zeldow BJ. [12] Grahnen H. II.5:153. Artaza LP. Oral Surg 1964. et al. Brehmer B. Oral Surg 1983. Massone EJ. . Factors that influence the success of endodontic treatment. Endodontic status and suggested treatment in a population requiring substantial dental care. J Endod 1998. J Endod 1986. Kettering JD. Comparative study of retreatment of Thermafil and lateral condensation endodontic fillings. Tamse A.

Incidence of root fractures and methods used for post removal. [52] Imura N. Gutta-percha solvents—a comparative study. Endodontic retreatment with halothane versus chloroform solvent. Pehlivan Y. Wong / Dent Clin N Am 48 (2004) 265–289 [35] Wu MK. Siqueira EL.34(7):514. De Castro AJ.04 Taper Series 29 files in removal of gutta-percha root fillings during curved root canal retreatment. Sarfati P.25(9):627. Rosenberg M. Marshall G.38: 456. [50] Barrieshi-Nusair KM. The extraction of instruments broken in the radicular canal. Journal Calif Dent Assoc 1991. [40] Abbott PV. Wesselink PR. J Am Dent Assoc 1978. Evaluation of gutta percha solvents. [39] Ruddle CJ. Actual Odontostomatol 1959. El Deeb ME. Wilcox LR. Shibata T.16:52. Uemura M. Weine F. Ramos AA. Omnell KA. J Endod 1990. Frank AL. [43] Goon WWY. [45] Glick DH. [60] Jeng HW.12(3):208.23:4. [51] Betti LV. Morgan LA. [36] Simon JHS. Preliminary study on the effect of heat from ultrasonic preparation on the buccal cortical bone during post and instrument removal.19(3):264. Iroh T. [37] Vertucci FJ. [42] Angmar-Mansson B. An experimental study of the removal of cemented dowel-retained cast cores by ultrasonic vibration. [58] Wilcox LR. Int Endod J 2002. A comparison of the relative efficacies of hand and rotary instrumentation techniques during endodontic retreatment. J Endod 1987. J Endod 1995.12(2):95.21(6):305. a new technique. Effectiveness of Profile. Kontakiotis EG.15:11. Frank AL. Hata GI. Sekine I. . J Prosthet Dent 1998. Removal of silver points and fractured posts by ultrasonics. Toda T. Baumgartner JC. [46] Machtou P. Root canal morphology of maxillary second premolar. Microendodonitc analysis of failure: identifying missed canals. Effectiveness of gutta-percha removal with and without the microscope. [54] Valois CR. Braz Dent J 2002. Microleakage along apical root fillings and cemented posts.20:245. University of the Pacific. Int Endod J 2001. Odontol Rev 1969. 2003. Gutta-percha retreatment: effectiveness of nickel-titanium instruments versus stainless steel hand files. In vitro study of effect of solvent on root canal retreatment. Rajamanickam I.26(2):100. Post removal prior to retreatment. Bramante CM. Quantec SC rotary instruments versus hand files for gutta-percha removal in root canal retreatment. [47] Masserann J. J Endod 1999. Effectiveness of the Profile.43:202. Actual Odontostomatol 1966. Rud J. Cohn AG. Gomyo S.12:8. Removal of hard paste fillings from the root canal by ultrasonic instrumentation. J Endod 2002. J Endod 2000. J Periodontol 1972.35(1):63. [41] Altshul JH.22(4):361. J Endod 1997.28(6):454.04 taper rotary instruments in endodontic retreatment. Comparison of dentinal crack incidence and of post removal time resulting from post removal by ultrasonic or mechanical force.23(11):683. Metzger Z. Root fractures due to corrosion. J Prosthet Dent 1986. The relationship of endodontic-periodontic lesions. Unger U. Gahyva SM.47:265. Managing the obstructed root canal space: rationale and technique. Lim BK. [57] Tamse A.55:212. [55] Kaplowitz GJ. Santos M. The extraction of posts broken deeply in the roots. [48] Yoshida T.75:329. J Endod 1986. [44] Masserann J.13:6.288 R. Braz Dent J 2001. [38] Vertucci FJ. Int Endod J 2000. J Endod 1997. Glick DH. J Endod 1989. Kato AS.19:51. Navarro M. Oral Surg 1974. Root canal morphology of mandibular premolars. [53] Sae-Lim V.16:539. 97:47. Journal Calif Dent Assoc 1997. [59] Baldassari-Cruz LA. [49] Gluskin AH. [56] Oyama KO. Lee HL.

Thermafil retreatment using a new ‘‘SytemB’’ technique or a solvent. J Endod 1999. J Endod 1997. Bolla A. [63] Bertrand MF. [64] Wolcott JF. Thermafil obturation: a literature review. Removal of Thermafil root canal filling material. Gen Dent 1997.25(11):761.45(1):46.23:1. Klinghofer A. Wong / Dent Clin N Am 48 (2004) 265–289 289 [61] Ruddle CJ. Dentistry Today 1996. Rocca JP. Donnell JC. Microendodonitcs: eliminating intracanal obstructions. [62] Becker TA. Himel VT.R. Hicks ML. 15:44. . Pellegrino JC.

Philadelphia. A physical barrier must be achieved at the perforation site to prevent MTA from being packed into the bone or through the pulpal floor into the furcation site. University of Pennsylvania. Even though MTA sets in the presence of moisture. the dentist should contact the local endodontist and request perforation repair on that same day. If the perforation occurs in a general dentist’s office. with less potential toxicity. as dry a site as possible should first be established because MTA (when mixed into a ‘‘sandy’’ slurry) is difficult to manipulate and to place. the area should be copiously irrigated with sodium hypochlorite. including various collagen-type materials such as collatape E-mail address: sikratch@aol. This irrigant is the one most commonly used in endodontics and will help to clean the site. 240 South 40th Street. Dentsply Dental. the most important step is to seal this perforation as quickly as possible. the goals are to ‘‘sterilize’’ (decontaminate) the site and then seal the perforation. Pennsylvania).cden. but most practitioners use a diluted form that is mixed with approximately 50% water.com 0011-8532/04/$ . MTA is extremely biocompatible.York.003 . All rights reserved. there are several materials available. The diluted solution of sodium hypochlorite is as effective as the full-strength solution for cleansing. PA 19104-6030. School of Dental Medicine. hemostasis and a barrier must now be achieved. Kratchman.Dent Clin N Am 48 (2004) 291–307 Perforation repair and one-step apexification procedures Samuel I.2003. USA As with any dental treatment.see front matter Ó 2004 Elsevier Inc. After a perforation occurs. and it has been shown histologically that osteoidlike material grows right into MTA [1]. procedural mishaps can occur during root canal therapy. DMD Department of Endodontics. avoiding potential contamination from surrounding tissues.1016/j. Before placing MTA over a perforation site. The material most widely used in endodontics to seal perforations is mineral trioxide aggregate (MTA. After the perforation site has been ‘‘soaked’’ with sodium hypochlorite for approximately 5 minutes. Full-strength sodium hypochlorite is 5%. To achieve hemostasis and a physical barrier. One such occurrence is the perforation of a root or pulpal floor.12. doi:10. When this occurs.

Three-year follow-up. 2. Fig. . 3. Kratchman / Dent Clin N Am 48 (2004) 291–307 Fig. 1.292 S.I. Perforation sealed same day with calcium sulfate and MTA. Fig. Perforation made with an overly aggressive post system.

Four-year follow-up after perforation repair. The microscope allows for precision in sealing these perforation sites. This procedure is best performed under a surgical operating microscope that provides great magnification and illumination [2]. Rome. 4. and while in a pastelike form. it can be placed through the perforation site using an S-Kondenser (Obtura/Spartan. Carlsbad. California) and calcium sulfate (Class Implant. Old furcation perforation that was not sealed. 5.S. (Centerpulse Dental.I. Kratchman / Dent Clin N Am 48 (2004) 291–307 293 Fig. only a small amount of material is required and the working time is fairly short. Italy). If choosing calcium sulfate as a barrier. . The calcium sulfate powder is mixed with a liquid that is packaged together. These materials are resorbable and are needed to help create a dry field and a solid area against which the operator packs MTA. Fig.

After placement.I. Fenton. Missouri). The barrier is now in place and MTA is ready to be placed. depending on the size of the perforation. The proper sized S-Kondenser is chosen before the calcium sulfate is mixed. The S-Kondensers come in three sizes and are doubleended. Repair with collatape and MTA. . Fig. 6. 7. with one side made of stainless steel and the other end made of nickel–titanium. the calcium sulfate will set over the next minute or so to a stonelike consistency. Kratchman / Dent Clin N Am 48 (2004) 291–307 Fig.294 S. Lateral lesion associated with perforation of mandibular bicuspid.

I. MTA will be fully set and the tooth can be permanently restored. Originally. ESPE. In these cases. MTA is now white and the manufacturer claims there are no changes in the physical properties. One-year follow-up. in that it can prevent renegotiating the canal if the perforation is in the canal or very close. so the recommendation is to place a moist cotton pellet on top of the MTA and to fill the access with a temporary filling material (eg. gray MTA. it is paramount to try to keep the canal patent and . MTA powder was gray in color and when mixed.S. cavit. MTA has a much longer working time than calcium sulfate and if it appears too dry. MTA is placed using the S-Kondensers and abuts to the barrier that is already in place. but mixing it tends to be a bit more technique sensitive. There can be additional problems when a perforation occurs. MTA will set over the next several hours under the moist cotton pellet. Therefore. so at the next appointment. 8. it can simply be rehydrated with sterile water or anesthetic solution. looked like sand and hardened to a concretelike consistency. Kratchman / Dent Clin N Am 48 (2004) 291–307 295 Fig. when the tooth is accessed. Pennsylvania). When sealing a perforation in the cervical portion of an anterior tooth. Norristown. this gray MTA was not esthetic. White MTA is creamier when mixed and a little more difficult to manipulate but sets as hard as the original. MTA sets in the presence of moisture.

9. Clinical cases Case 1 Perforation made with an overly aggressive post bur [3] (Figs. 1–3).I. This perforation was sealed almost immediately. using a barrier of calcium sulfate and MTA. Kratchman / Dent Clin N Am 48 (2004) 291–307 Fig. perhaps leave a file or paper point in the canal while using MTA so as not to block the canal. The 3-year follow-up shows no signs of bone loss in the furcation and no clinical depth greater than 2 mm.296 S. Maxillary incisor with open apex. .

The follow-up radiograph shows that this case was successful. using calcium sulfate as a barrier and MTA to seal the perforation. 4 and 5). and this situation along with the amount of time between the perforation occurring and being sealed (allowing for contamination) decreased the prognosis for this case [4]. Calcium sulfate placed as an apical barrier and obturated with gutta percha. Case 2 Perforation occurred during retreatment by one endodontist and was referred to a second endodontist after several weeks (Figs. . The aforementioned technique was performed. This perforation was through the pulpal floor.S. Kratchman / Dent Clin N Am 48 (2004) 291–307 297 Fig.I. 10. with furcal bone intact and no periodontal probing depth greater than 2 mm.

Case 3 Retreatment case of a mandibular bicuspid with an existing perforation from the first endodontic treatment that most likely occurred while the practitioner was looking for an additional canal (Figs.I. the clinician must be careful not to block the . 6–8).298 S. The preoperative radiograph for the retreatment shows bone loss on the lateral side of the root due to the perforation and shows a periapical lesion due to the fact that an untreated canal existed [5]. One-year follow-up. Kratchman / Dent Clin N Am 48 (2004) 291–307 Fig. 11. What makes this case even more challenging is that while sealing the perforation on the lateral side of the root in the midroot region.

canal with the barrier material. The missed canal was located after the gutta percha was removed from the other canal and both canals were treated. collatape was chosen as the barrier material. This collagen membrane resorbs. Collatape comes in strips of ‘‘collagen-type’’ material that the clinician folds into a small piece and. packs it through the perforation site into the surrounding bony space. Maxillary incisor with blunderbuss apex and thin walls. 12. which can more easily be manipulated and packed through the perforation while maintaining the patency of the canals. While in the process of warm vertical obturation.S. Kratchman / Dent Clin N Am 48 (2004) 291–307 299 Fig. so it is acceptable to be extruding into the surrounding bone/tissues of a tooth. For this reason. with the S-Kondensers.I. especially because there is also a second canal that needs to be negotiated for the first time. the gutta percha was removed .

A 1-year radiographic follow-up shows healing of both the periapical and the lateral lesions. and then a layer of MTA was placed to seal off the site and the other canals were obturated with warm gutta percha. 13. cases with open apices were often treated over several .300 S. One-step apexification Another use for the barrier/MTA technique is for one-step apexification cases. Physical barrier of calcium sulfate beyond apex and MTA in apical third of canal. with no periodontal probing depth greater than 2 mm. apical to the perforation site. In the past. Kratchman / Dent Clin N Am 48 (2004) 291–307 Fig. making room to pack the collatape out through the perforation.I.

extending treatment over a long period of time without providing a permanent restoration increased the chances of losing these teeth due to fracture.I. therefore. with the hope of creating a ‘‘calcific’’ barrier against which gutta percha could eventually be placed. the aforementioned materials can be used to create an apical barrier and to safely obturate theses canals without worrying about extruding gutta percha into the apical tissues.S. appointments. Similar to the technique described previously for sealing perforations. Kratchman / Dent Clin N Am 48 (2004) 291–307 301 Fig. more brittle. The treatment could be as long as a year. Calcium sulfate and MTA are . These roots were often thinner and. 14. with still no establishment of any apical barrier formation. using intracanal medicaments. Gutta percha obturating remainder of canal.

Kratchman / Dent Clin N Am 48 (2004) 291–307 Fig. 15. with vertical compaction of warm gutta percha. the rest of the canal can be easily filled using the Obtura II (Obtura/Spartan. . size 100 to 140 K file) so as to better gauge the depth of the calcium sulfate/ MTA placement by moving the rubber stopper down the file coronally as more material is placed in the canal. Two-year follow-up. require an entire pack of accessory gutta percha points.I.302 S. Fenton. Missouri). Before the advent of warm vertical condensation. After MTA is firmly packed. placed using either an amalgam carrier or the flat end of a Glick condenser and packed down the canal with S-Kondensers and using the last size file (ie. and still often end up with voids. filling cases such as these would be time-consuming.

California) and backfilling with the Obtura II. A 1-year radiographic follow-up shows intact periapical bone and no sign of pathology. Instead of MTA in this case. a master cone of gutta percha was placed with tug back. . Clinical cases Case 4 Figs. and then completed by removing all but the apical 5 mm of gutta percha using the System B heat transfer unit (Sybron Endo.I. Maxillary incisor with open apex. Kratchman / Dent Clin N Am 48 (2004) 291–307 303 Fig. 16.S. confirmed radiographically. 9–11 show a maxillary central incisor with an open apex in which calcium sulfate was placed and a firm apical stop manufactured. Orange.

304 S. . Radiographic follow-ups at 2 years show complete healing periapically and no pathologic signs. Kratchman / Dent Clin N Am 48 (2004) 291–307 Fig. extruding into the periapical area but forming a physical barrier against which MTA can be packed at the root end. Canal filled with calcium hydroxide to attempt apexification. Why not fill the entire canal with MTA? There is really no benefit to doing this because MTA is much more expensive and more timeconsuming to place than gutta percha. Case 5 Figs. calcium sulfate was placed apically. 12–15 show a maxillary central incisor with a blunderbuss apex and thinner walls than the previous case. To create a barrier.I. 17. and the rest of the canal is obturated with warm gutta percha [6]. MTA fills the apical 3 mm of the canal. A small periapical lesion is present. An often-asked question is.

the one-step apexification technique was performed. 16–19). but the radiopacity is almost identical. still no calcific barrier apically. Case 6 Maxillary central incisor with an open apex in which apexification was originally attempted by multiple calcium hydroxide placements [7] (Figs. using calcium sulfate and MTA. .S. 18. Kratchman / Dent Clin N Am 48 (2004) 291–307 305 Fig. and the final gutta percha placement. A radiograph confirms the calcium sulfate in place (sealing off the apical tip of the root). After this failed attempt to create a calcific barrier.I. After several placements of calcium hydroxide. A slight demarcation can be seen between MTA and gutta percha. MTA in the apical few millimeters of the canal.

McDonald F.24:543–7. Completion of these cases in an effective and efficient way allows for permanent restorations to be done in a more timely manner.I. J Endodon 1998. . 19. Kratchman / Dent Clin N Am 48 (2004) 291–307 Fig. Pitt Ford TR. MTA. With the favorable histologic response of MTA. Torabinejad M. References [1] Koh ET. this material is the best current choice for this procedure [8].306 S. This technique of one-step apexification offers an alternative to those drawn-out cases with several medicament-changing appointments that often resulted in a failed attempt at root-end closure. Cellular response to mineral trioxide aggregate. One-step apexification with calcium sulfate. prolonging the longevity of these teeth. and gutta percha.

19:541–4. Karyiyawasam SP. [3] Akkayan B. J Endodon 1993. Treatment of teeth with open apices using mineral trioxide aggregate. Torabinejad M. J Endodontics 1999. Pract Periodontics Aesthet Dent 2000.87:431–7. Kratchman / Dent Clin N Am 48 (2004) 291–307 307 [2] Carr OB. In: Clark’s clinical dentistry.25:197–205. Torabinejad M. Roberts OJ. Clinical applications of mineral trioxide aggregate. Use of mineral trioxide aggregate for repair of flircal perforations. St. J Prosthet Dent 2002. .183(3):241–6. Sealing ability of mineral trioxide aggregate for repair of lateral root perforations. vol. 1–14.S. Oral Surg 1995. 4. Monset M. p. Magnification and illumination in endodontics.79:756–62. Gulmez T. Louis (MO): Mosby. Use of calcium hydroxide for apical barrier formation and healing in non-vital immature permanent teeth: a review. Hong CU. [8] Torabinejad M. [5] Lee SJ. Chivian N. 1998. [6] Shabahang S. Br Dent 1997. Torabinejad M. [7] Sheehy EC. McKendry DJ. Resistance to fracture of endodontically treated teeth restored with different post systems. [4] Pitt Ford TR.12:315–20.I.

perform comprehensive charting.b. All rights reserved.com 0011-8532/04/$ . E-mail address: guessendo@mac. but the method of delivery and presentation has changed thanks to improvements in technology on many fronts. this article reviews the process of reaching the goal of modernizing a new or existing endodontic office. most apparent. 240 South 40th Street. DDSa. Most influential in this change has been the widespread use of computers and computerized peripherals in providing dental treatment and educating patients about the treatment they are to receive. to take and store digital radiographic images. the overall design of the modern dental office to allow the use of and to take advantage of these technologic changes. do billing.004 . and in more advanced cases.cden. CA 92122. which represents the use of computers to share and maintain information. It is not rare to find a modern endodontic practice using computers to capture digital video and still images of treatment. greater efficiency is achieved on many levels. has had many influences in the field of dentistry. and to chart the patient’s treatment information. San Diego. Suite 209. The most important advances in * Private Practice. Suite 209. CA 92122. store patient information.2003.1016/j. For many years. 8929 University Center Lane. USA b Department of Endodontics. especially in endodontics. San Diego. By using a computer system to manage the information used by the practice.Dent Clin N Am 48 (2004) 309–321 Modern office design in the ‘‘information age’’ Garrett Guess.* a Private Practice. The information age.see front matter Ó 2004 Elsevier Inc. Philadelphia. Like putting the pieces of a complex puzzle together. computers have been used to schedule patients. Computers in the dental practice are not a new occurrence. PA 19104-6030. The focus of providing superior and effective patient care remains the same. USA The modern dental office in the ‘‘information age’’ of today bears little resemblance to the offices built 20 or even 10 years ago. University of Pennsylvania School of Dental Medicine. These influences have begun to change the daily practice of dentistry by affecting the standard of care and. doi:10.10. Most of the advancements in the modern endodontic office revolve around the use of computers that act as ‘‘hub’’ between the various components. 8929 University Center Lane.

Eventually. the hardware on which it runs. whether it is looking up when a patient is scheduled or retrieving their chart and associated radiographs. and scheduling information are forms of databases. storing patient data in a practice management program. Given this design. The gain in efficiency easily can be seen on many levels. which translates to less cost of maintenance and less downtime. Whether it ranges from creating documents. or manipulating digital video and images. the Apple Macintosh systems). The specific hardware requirements will be dictated by the practice management software program. 1). and capability to perform just about any needed task in the dental office. Instead of using wall space in an office to store paper charts. seeking the advice from a computer consultant is invaluable. a computer system uses hard drive space in a computer to digitally store a patient’s information. Computer programs that maintain patient information. Therefore. then the dentistry practice will likewise be inefficient . the hardware available to the private practice endodontist or dentist is affordable and capable. and the network that connects it all together.310 G. Databases allow the storage of all types of digital information that can be retrieved and stored with minimal cost and maximal efficiency. Because the software program ties in all of these technologies. the days of searching through reams of patient charts will be gone because the computer programs allow searching the office database with instantaneous and accurate results. flexibility. choosing the appropriate hardware comes down to esthetics. Some computer systems use more intuitive operating system software and have greater stability (eg. and the peripheral video equipment used. The computer hardware available today has the speed. So many functions of the practice hinge on this choice and there are a lot of offerings available. If the program is inefficient or incapable. performance. Considering how important the tasks are that the program manages. it is clear why this decision has to be made wisely. In an office where everything is stored in the computer. Guess / Dent Clin N Am 48 (2004) 309–321 the dental office come with the software that manages all of the vital information used in the practice. it is one of the best places to start looking when deciding what is needed to upgrade to a modern office (Fig. a computer system allows instantaneous access of information. cost. and compatibility with peripherals and practice management software. The choice of hardware is an important one: it can mean the difference between a transition full of ease/success and a constant headache. A consultant can plan the requirements within a certain budget to get the job done. the digital radiographic system. The key to a modern endodontic practice’s organization and efficient operation revolves around the stability of the computers that run practice management software programs and other peripherals. Choosing a software program to manage the office could be one of the most important decisions to make when considering the transition to a computerized office. the entire office is dependent on the computer program. digital radiographs. If one’s knowledge is minimal regarding computers and their related systems.

Guess / Dent Clin N Am 48 (2004) 309–321 311 Fig. San Diego. a program designed specifically for the endodontist often will be a wiser choice over one for dentists in general. the choice of stable hardware on which to run the software is important. The various practice management software packages available perform the same overall function. Therefore. Considerations with regard to expansion and compatibility are also crucial. and all may work well for an endodontic office. or incapable. The flow of treatment planning. as is the setup of the system to ensure that it is trouble-free. There are dozens of computing solutions to manage the dental practice. but different programs do it in very different fashions. Practice management software is the hub connecting and managing all other technologies utilized in the endodontic practice. Because the financial and time investment is large when purchasing programs and training personnel to use them. California) and was developed by the author. certain programs are designed for specialty practices. The Windows solutions are PBS Endo (PBS. and other issues will be better suited to the daily routines and management of a specialty practice. Inc. Each of these systems provides comprehensive charting. referral management. San Diego. There are currently four ‘‘endodontics-only’’ software packages: three are available for Windowsbased computer systems and one for Macintosh-based computer systems. As an endodontist. The Macintosh system is called EndoTrak (Digital Database Systems. EndoVision (Discus Dental. 1. whereas others are made by consultants and computer programmers. The abilities of a software program to efficiently incorporate different peripherals such as video input from a microscope or a digital still . referral. These systems all focus on the specific needs of the endodontist in their own ways and have specific pluses and minuses that need to be evaluated by the prospective dentist when choosing between them.G. California). and practice management. Texas). California).. whereas others are made for a dental office in general. and TDO (DogBreath Software. the longevity of the system is important. Culver City. Some systems are designed by practicing dentists. and some systems have severe limitations when it comes to expansion or upgrading—all of these factors are important to consider. which are important in an endodontic practice.

there are different types of networks available: wired and wireless. a clear decision can be made as to the best system for the specific application. listen to their experiences. changed. All dental practices are different. The software will need to be able to support this upgrade. Guess / Dent Clin N Am 48 (2004) 309–321 camera and to link with a digital radiography program are essential. planning is required and a contractor needs to be employed run the wires to all needed locations throughout the office. The current wireless systems do not have the speed capabilities of the standard wires and are susceptible to interference issues. These important attributes of a computer program can only be noticed when enough time is spent using and understanding the system through either a demonstration or training session. then the program will have to have the capability to be networked to allow access to patient information from different locations in the office. Today. which make them unacceptable in most dental practice settings. and other equipment needed to perform certain functions. searched for. Because the computer program ties together the pieces of technology in the office. so thinking ahead when reviewing the current and planned features is important. Wireless systems have tremendous flexibility in environments where wires cannot be placed due to feasibility or economics.312 G. the choice of the software program should follow exactly the technology goal of the practice. Time is needed to get a feel for the ‘‘thought process’’ that a particular computer program uses. and visit their offices. The front desk needs to know the treatment performed to properly collect the fees. and stored. the front desk will work with and maintain the patient information while the back office will work with that patient’s chart for the day. an office may not want to start immediately with digital charting but want that capability in the future. It always is smart to plan ahead for expansion by running extra wires that may be used in the future. To have computers in the operatories linked to share patient information. If digital charting is desired. Some programs can be intuitive and simple. Endodontics is one field that has taken advantage of this technology—the ability to document treatment with digital still and video imaging. Therefore. a computer network has to be present. A wired network is the preferred method (which involves wires to be run to each location where a computer is present) because it is the most robust method of interconnecting computers. For example. It is even more helpful to test the programs using a demonstration copy because often it is difficult to get the full sense of a program when a salesman is present. Computers have changed the landscape of digital imaging and its ease of use in many environments including dentistry. whereas others may be very complex and do not interact in a predictable or commonsense manner. power outlets. Endodontists often will want to take . The infrastructure includes the wires. This thought process is the manner in which information is entered. In this way. Having the infrastructure present to support these capabilities is a prerequisite. The only way to get accurate information to make an informed decision is to talk to users of different software programs.

The infrastructure requirements of this capability will not only require the power and video cables to be present in the walls but the computer hardware and software also must support the function of multiple displays or video mirroring. To perform this function. These images can be added to a patient’s chart or put in a report to share with referrals. Guess / Dent Clin N Am 48 (2004) 309–321 313 pictures with the operating microscope. The majority of microscope manufacturers have the ability to output a video signal from an optional camera mounted within the microscope. a monitor for the assistant to view during treatment is helpful to allow data entry into the chart as treatment is occurring. whereas another screen can display the working radiographs for the doctor to reference on the doctor’s side of the operatory (Fig. For example. having a display behind the patient allows for the viewing of radiographic images in the manner similar to viewing conventional film with respect to the tooth location (Fig. Where Hi-8 8-mm video tape decks were used to record surgical procedures. the proper wiring that links the microscope and the computer needs to be present. Flat-paneled monitors take up little wall space and are simple to wall-mount. 3). it is beneficial to have several displays that show the output from the computer. so it is possible to place these screens in different locations with ease. The exact placement of the multiple monitors is determined by each dentist’s preference. a computer can now record the video with digital quality that can be edited into educational and informative media with many uses. one computer screen with which the assistant can interact can show the chart for data entry during treatment and is placed at the 12 o’clock position in the operatory. The evolution has been spurred by the changes and new technologies incorporated in the computer systems themselves. It allows a patient or referral to see exactly what is being treated.G. When viewing video images and patient charting in the operatories. With tighter integration of many software components. Especially with digital radiography systems. . Also. Recording and presenting this media to patients and referrals is an impressive method of education and relaying information about treatment plans and outcomes. It is clear that as more functions are added. Planning the current and future wiring needs should be closely evaluated before construction or remodeling begins to account for all possible configurations that may be tried now and in the future. Documentation using images is invaluable with respect to certain liability and consent issues. This connectivity allows a computer program to import and store video and still images that are seen through the operating microscope camera. and this capability should be considered as part of the requirements of the imaging system. Computer systems have evolved tremendously over the last 5 years. Still imaging is handled by computers in the same way. Capturing images can easily be done using computers that can import digital video through a capture card or similar device that converts the analog video signal from the scope into a digital signal that the computer can use. 2). computers have been able to tackle just about every task presented in a tight-knit fashion. demand for a more complex infrastructure arises.

Unfortunately.314 G. the largest hurdle to overcome is learning the software program that manages the office. The best and most capable software program linked to a high-quality video recording system is a waste of time and money if it is not used efficiently. Computer monitor placement on the wall behind the patient for flexible computer viewing and input by the staff and/or doctor. The doctor and staff must understand and be fully capable of using the new technologies to their fullest extent to make the transition worthwhile and less disruptive. Some of these . digital images can be stored and sorted for each patient with little turnaround. Usually. Instead of a photographic film-based camera system. learning new technologies can be very difficult. As the complexity of the technologies and their related systems increases in the dental office. so does the requirement of an increased knowledge base for those who use the equipment. 2. especially for those who are unaccustomed to computers and their usage. Guess / Dent Clin N Am 48 (2004) 309–321 Fig. These images can be transferred to a digital chart of the patient and stored for later viewing or sent to referrals or benefit providers.

4). When hiring personnel in the modern dental office. No longer is information in an irretrievable. A networked dental office can share all parts of patient information between the front office and operatories and remotely between separate offices in different locations. With . Guess / Dent Clin N Am 48 (2004) 309–321 315 Fig. One of the most substantial changes in a modern dental office is the ‘‘movement’’ of computers from the front office to the operatory where patients are treated. computer systems in separate office locations can be linked for a reasonable cost by means of the Internet. videos.G. but not today. programs have such a large number of features that it is a challenge to master them all. Doctor and staff working shown with an operating microscope and integrated video camera. it is important to research the training and experience of potential employees because training is a difficult and long process when starting at ground zero. Most companies offer training manuals. a networking infrastructure is used to share information among the computers in the office (Fig. Taken one step further. displaying the video through a chairside computer station. and training sessions to familiarize the office with their programs. With the addition of computer workstations in the office. Computer software systems that manage the dental practice allow the archiving and storing of countless numbers of patients. The efficiency of this arrangement over an older written patient chart is incredible. The other equipment such as the setup of the servers and the network can be left to contracted consultants. All information stored within these records can be sorted and sifted through instantaneously. inefficient storage state—the written patient chart. 3. This complexity can be achieved thanks to significant advances in the hardware and software that allow these capabilities. Such complexity would have required a full-time staff of trained network experts just 10 or 15 years ago. Dental offices have approached enterprise-level complexity in the use of computer systems and the networks that link them together.

. Guess / Dent Clin N Am 48 (2004) 309–321 Fig. radiographs. The Internet has made communication among colleagues a facilitated process. the postoperative reports and radiographic images of patients can be electronically mailed to referrals directly using many of the computer programs available today. especially with regard to sharing digital media about patient treatment (eg. It is common now to come across a dental office with a computer network as advanced as any large business or enterprise. and between offices to permit the sharing of patient and practice data. and software systems. the workforce has a greater number of consultants familiar with networking. 4.316 G. Network connections between computers in the same office. this efficiency continues to increase. A computer network is no longer something limited to large businesses with large technology budgets. so the cost of installation and maintenance has decreased significantly over the past 10 years. Of the technical aspects of the modern office. A complex network of computers managing a dental practice has been facilitated by the increased capabilities and utility of today’s computer and software systems. increased power and capability of computer hardware. one of the greater advancements of the information age is the increased networking ability of computer systems today. In endodontics. thus allowing for more efficient follow up turnaround. which is possible through advancements in technology in the hardware and software of today’s systems that makes having a network a simple process. and videos). images. networking. Even patient insurance benefit inquiries and claims submissions can be quickly and accurately handled by communicating over the Internet. This permits general practitioners and specialists to work together in a much more efficient and exacting manner. The increased ability to share information is making communication among colleagues faster and more effective by providing better information in the form of images and even video of treatment performed. irrespective of their office proximity. In addition. This facilitated sharing allows colleagues to confer and share their ideas and experiences in great detail.

significant findings can be obtained. to access treatment information for the patients in the office. and does not require maintenance of the processing equipment. With a standard film. another film needs to be taken and there is a chance that the same image may be taken again or another improper angle may result because the entire film assembly is removed and then replaced. and with an efficient method to track and study this information. This system has the advantages of data portability and security because data are on a secured server that is frequently backed up in case a problem occurs. Clinical research capabilities have been strengthened by the use of computerized charting systems in dentistry. does not require a significant time lag in the development process. This information is invaluable because some procedures work well in some doctor’s hands. By not having to move the sensor in the patient’s mouth. Guess / Dent Clin N Am 48 (2004) 309–321 317 A new type of practice management software system is designed to take advantage of the networking capabilities of the Internet. then the x-ray cone can be moved slightly in one lateral direction and the sensor re-exposed. Through this kind of setup. For example. Instead of the usual in-office computer server. when an incorrect angle results.G. documentation. With the lack of published clinical research data from private practice practitioners. this powerful feature of increased technology has exciting potential. Digital radiography has become a diagnostic tool that many dental offices are taking advantage of for many different reasons. Direct digital x-ray sensors are most helpful in endodontics by providing the ability to expose the sensor multiple times without removing it entirely from the mouth. This method is less popular but likely to be the ‘‘wave of the future’’ as Internet reliability and security increases. 5). especially in multirooted teeth . The ability to expose a sensor to radiation and have the image appear in less than 10 seconds on a computer screen is a proven utility (Fig. This feature enhances the midoperative diagnostic accuracy of the practitioner. This type of information allows a private practice clinician to have an evidence-based practice using data from his or her own practicing techniques. whereas others do not. patient charts and information can be accessed anywhere that access to the Internet is available. This allows subtle repositioning of the x-ray cone to get various angled images with greater accuracy and less retakes. the server is accessed over the Internet using a Web browser instead of proprietary software like most practice management software programs. It is clearly more efficient than chemical processing. and education to be changed. Therefore. more accurate changes in angulation can be performed. A computer system in the treatment operatory allows many aspects of treatment presentation. if a midoperative working radiograph is taken and one root is superimposed on another. the server with all of the office’s information is located off-site and managed by an outside company. Storage of clinical treatment information in a digital form allows practice management software programs to perform searches that allow a clinician to track success and failure with regard to many different variables.

there are no chemicals to maintain or change. and patient health benefits because the radiation dose exposure is significantly decreased. by the type of monitor or flat panel that is used because all systems have similar high-quality sensors and resolution capability. the file sizes are extremely small relative to the storage available. so a computer is required in each operatory. because each root end can then be visualized over a series of angled digital radiographic images before progressing. so digital radiography has no ‘‘per-use’’ cost other than the storage space on the computer that the digital image file requires. The benefits of digital radiographic systems are clear. Digital radiography also has several staff. For this reason. but it is the high cost of the system that keeps most offices from making the change. Compared with the fastest E-speed film that may require a 20-millisecond exposure at 70kVp. Digital xray system: wired sensor connected to a USB interface with the computer. doctor. with most systems using newer image compression routines. digital radiography must be used with a computer that controls the radiographic system. therefore.318 G. The exposed sensor produces an image on the computer display for viewing and manipulation. 5. The resolution of the current digital radiographic systems is very good. To get . In addition. greater than most computer screens can display. Also. which is close to a seven-times decrease in radiation exposure to the patient. Guess / Dent Clin N Am 48 (2004) 309–321 Fig. Digital radiography allows the doctor to more easily view the image and greatly facilitates educating the patient because it allows a large screen-sized image to be viewed on the monitor. high-quality computer displays are an important investment when considering the purchase of computer equipment for the modern dental office. the same quality image can be obtained with a digital radiographic system using just 3 milliseconds of exposure time with the same 70kVp. The image quality is mostly determined. From a waste and materials-usage standpoint.

A technology goal consists of looking at the current state of the practice at three levels: budget. knowledge base. The best way to sample all systems at once is usually at dental trade shows where one can go from booth to booth to see each system and have the competition freshly in mind. but this technology is well worth the money. and peripherals. especially in endodontics for the reasons mentioned earlier. it is advisable to try different systems to see which one works for the particular tastes of the office. all of which still incur significant cost.000 per operatory. which is invaluable when explaining treatment to patients. To aid in the decision. Guess / Dent Clin N Am 48 (2004) 309–321 319 around the expense of equipping an entire office with a network and computers in the operatories. some practices use a laptop that is carried between operatories or a computer that is on a wheeled cart that can move from one operatory to another. then a Macintoshbased digital radiographic system is necessary so that new computers will not be needed when the transition is made. practitioners should get one that has the potential to work with the practice management solution they are most likely to purchase. the resolution of all systems is comparable. As mentioned earlier. There are approximately 20 digital radiographic sensor systems available today. A sound budget is important because the incorporation of technology costs significant time and money. Peripherals such as digital radiography incur a large expense. Time is needed to train staff on new systems that are introduced and time is required for the days that the office is not open when the infrastructure is being constructed. If a Macintosh-based practice management software system is preferential. but the differences in software. sensor size. these unbiased opinions are the most valuable ones obtainable. There are many ways to do this. and especially price are what distinguish systems from each other.000 to $14. it is advisable to ask colleagues in the field about what works well for them. which does not include the computers that run the software and manage the sensors. software. The need is clear to incorporate computer-based technologies in the office. It takes significant amounts of money to purchase the expensive equipment required: computer hardware.G. Systems today range in price from $6. Current computer systems cost about $1200 for each unit. As always. some digital radiographic systems work best or even exclusively with certain practice management programs. When choosing a digital radiographic system to use on its own. Choosing a digital radiographic system is similar to picking practice management software. Almost all microscope companies provide the option of an integrated video camera. The best way to plan any endeavor is to map out a technology goal. All of this combined can be one of the largest purchases made by a dental practice during its construction. This option adds a significant cost (in the range of several thousand dollars) to the . whereas a server computer to host the computer program can cost four times that amount. service. and infrastructure. warranty. and getting there requires significant planning. with most of them being Windows-based and 4 being available for the Macintosh-based computer systems.

In fact. but its use. A Web site can set the tone of a practice and ease tensions by giving patients pictures so that they know what to expect. Digital still cameras also can be mounted to the operating microscope to take high-quality still images. purchase. as thousands of successful dentists have proved over time. sometimes making the scope less maneuverable. and Web sites enable them to do this. patients can be impressed and educated by the treatment they receive. All offices should take advantage of a Web site because it is a relatively inexpensive marketing tool that can be used effectively for introducing the practice to anxious patients. however. and then learn new equipment. It makes a greater impact on a patient to see a video of a procedure as seen through a microscope or to see the digital radiograph of their tooth on the computer screen than it does to be told information that they may not understand. often. The defining feature of a modern dental office is not the equipment alone. and is often more bulky and less aesthetic that the integrated unit. When images are obtained—producing printed media for the digital radiographs. Through ‘‘high-impact’’ patient education using the tools available today and in the future. Can a practice thrive without the use of computers and their related peripherals? It certainly can. In addition. Times are definitely changing. Time is needed to research. It makes a much greater impact on a patient to be able to see their own tooth and the conditions it may have versus a drawing or generic photograph. They are learning more and are becoming more accustomed to seeing technology in all parts of their own lives and are expecting dental offices to follow suit.320 G. For better or for worse. changes in the way procedures are being performed. postoperative reports. making the acquisition of technology not only a benefit from a patient treatment standpoint but also an effective and necessary marketing tool. The cost of the adapters and camera is similar to an integrated video camera system. competition among dentists and especially specialists has become increasingly greater in many urban and suburban locations. There are many high-quality. Greater technology and complexity requires greater education and. this is where Web sites play a large role in marketing the dental practice. or images—there are many economical printing solutions that can be used. patients are increasingly using the Internet to research the treatment they are about to obtain and the biographical information of the dentist doing the treatment. Guess / Dent Clin N Am 48 (2004) 309–321 already-expensive operating microscope. inexpensive ink-jet printers available that provide excellent output that can be given to patients or sent to referrals or insurance providers. Many patients like to ‘‘put a face to their doctor’’ before coming to the office. The added weight of the still camera and attachments on the scope head is another drawback to this type of digital imaging solution. the technologies driven by computers and their capabilities are a necessity in the successful and efficient dental practice. new software . Patients are more aware than ever before of the technologies that are available to dentists.

and power infrastructure of the office will not require any changes for a long time. What is advanced today will quickly and inevitably be improved on in the near future.G. all dental offices will be using digital radiographic systems. Computer hardware itself will need to be upgraded over time as the demands of software and other systems always seem to increase. . Making the transition to the modern dental practice is expensive and time-consuming but also profitable and exciting. Fortunately. Going 100% paperless is not the best solution for all practices. By building a foundation that is prepared to handle changes in computer demands. making this transition a smooth one. but the time is getting closer where this is increasingly becoming a reality and an expectation of patients. As computer familiarity and the staff knowledge base increases with the growing use of computers in society overall. Through careful planning and formation of a reasonable technology goal. There is so much to learn in this process and so much to keep up with because the technology changes rapidly. finding the office personnel able to harness the efficiency and power of the technology in the dental office will be easier. video systems. it is hoped that the networking. hardware development and updates tend to be far ahead of the needs of current dental software and peripheral demands. These features make up the modern dental office of today and of tomorrow. Guess / Dent Clin N Am 48 (2004) 309–321 321 programs. By making the right decisions in software type and video and radiographic systems. The hardware needs to be able to efficiently handle more features as they are added. and most difficult. wiring. keep up with the changes. planning for the future is possible. updating an old office or creating a new modern endodontic practice with the technologies of today can be an enjoyable reality from which practitioners and their patients can benefit. Soon. and patient charting programs that use no paper documentation.

0011-8532/04/$ .1016/j. Bekir Karabucak. clinicians are making treatment decisions without any support of scientific evidence.Dent Clin N Am 48 (2004) 323–335 Endodontic working width: current concepts and techniques Yi-Tai Jou.edu (Y. Donald Liu. In addition. DMD. DMD Robert Schattner Center. DDS. canal surface irregularities require proper instrumentation for adequate root canal filling. DMD. DMD*. it is still not clear how large is large enough. however. * Corresponding author. Gutierrez and Garcia [2] showed that often. School of Dental Medicine. canals are improperly cleaned. Haga [1] found that mechanical preparation of root canal to two sizes larger than the original was still not adequate. Without proper chemomechanical instrumentation. 240 South 40th Street Philadelphia. mechanically and chemically removing microorganisms and their substrates from the canal.see front matter Ó 2004 Elsevier Inc. Jou).006 . Many studies have demonstrated that widely accepted endodontic cleaning and shaping techniques are inadequate.-T. University of Pennsylvania. MS. They attributed this inadequate instrumentation to the fact that the root canal diameter is larger than the instrument caliber used in each particular case.cden. Walton’s [3] histologic study showed that canals that were instrumented to three sizes larger still were not thoroughly cleaned. This finding suggests that each canal should be calibrated independently before instrumentation so that proper preparation can be achieved. or other instrument motions and usage and always stress the importance of enlarging the canal size.upenn. reaming. E-mail address: ytj@pobox. Jeffrey Levin. In the absence of a study that defines what the original width and optimally prepared horizontal dimensions of canals are. USA A clinician’s primary concern is to thoroughly cleanse the root canal system during root canal therapy. PA 19104-6030. doi:10.2003. All rights reserved. the remaining irritants may reduce the success rate and cause failure of the treatment. Department of Endodontics.12. Recent in vitro investigations [15] concluded that stainless steel and nickel–titanium (NiTi) rotary instruments were not able to clean the root canals satisfactorily. Many textbooks and much literature focus on canal instrumentation in terms of filing. Without solid scientific evidence.

Unfortunately. Current studies pay more attention to the shape of the canal systems and its clinical implications than to the actual. most investigations have involved counting the number of canals and foramina and categorizing how the canals join or split. Until recently.9]. The horizontal dimension of the root canal system is not only more complicated than the vertical dimension (root canal length or working length) but also more difficult to investigate because the horizontal dimension varies greatly at each vertical level of the canal as shown in Figs.324 Y. This article provides definitions and perspectives on the current concepts and techniques to handle WW (the horizontal dimension of the root canal system) and its clinical implications.5–7.9]. the faciolingual direction of the routine radiograph gives an impression of a round-shaped distal canal. most morphometric studies cannot show the true picture of the horizontal dimensions of the root canal system. It is difficult to section all levels of the teeth and make the section plane exactly perpendicular to the canal curvature. . 1. this area of critical information has not been investigated thoroughly. 1–3.8.8. Jou et al / Dent Clin N Am 48 (2004) 323–335 Root canal morphology is a critically important part of conventional and surgical endodontics (root canal therapy).-T. Routine clinical radiographs may mislead clinicians to make a different plan to clean the root canal system. but there have been few clinical attempts to determine the working width (WW). Recent studies reported a high prevalence of oval root canals in human teeth [4. Many in vitro studies have recorded the scales and average sizes of root canals [1. Some clinicians may still have the impression that all root canals are round in shape because of such radiographs as shown in Figs. preoperative size of the canal [4. In the same tooth. Cross-sections of 90% of the mesiobuccal canals of maxillary first molars were found to be oval or flat [4]. Fig. Therefore. 1 and 2. The mesiodistally directed radiograph indicates a flattened distal root canal in a mandibular first molar.23].

3. . Cross-section of a mandibular first premolar. 2. indicating a long-oval and irregular root canal. the faciolingual direction of the routine radiograph may be mistakenly recognized as a round-shaped canal because a mesiodistally directed radiograph is rarely available clinically. The faciolingual direction of the routine radiograph gives an impression of roundshaped canal in a mandibular first premolar.Y.-T. the lesser and the greater initial horizontal Fig. The mesiodistally directed radiograph indicates a flattened root canal in the same tooth. Definition of working width The initial and postinstrumentation horizontal dimensions of the root canal system at working length and other levels are shown in Box 1. Jou et al / Dent Clin N Am 48 (2004) 323–335 325 Fig. In the same tooth. In a relatively round canal.

its MaxIWW12 is probably three to four times larger than MinIWW12. But 12 mm short of working length.-T. Definitions of the working width MinIWW(N) Minimal initial horizontal dimension N mm short of working length MinIWW0 Minimal initial horizontal dimension at working length MinIWW1 Minimal initial horizontal dimension 1 mm short of working length MinIWW2 Minimal initial horizontal dimension 2 mm short of working length MaxIWW(N) Maximal initial horizontal dimension N mm short of working length MaxIWW0 Maximal initial horizontal dimension at working length MaxIWW1 Maximal initial horizontal dimension 1 mm short of working length MaxIWW2 Maximal initial horizontal dimension 2 mm short of working length MinFWW(N) Minimal final horizontal working length MinFWW0 Minimal final horizontal length MinFWW1 Minimal final horizontal working length MinFWW2 Minimal final horizontal working length dimension N mm short of MaxFWW(N) Maximal final horizontal of working length MaxFWW0 Maximal final horizontal length MaxFWW1 Maximal final horizontal working length MaxFWW2 Maximal final horizontal of working length dimension N mm short dimension at working dimension 1 mm short of dimension 2 mm short of dimension at working dimension 1 mm short of dimension 2 mm short dimensions are approximately the same. Jou et al / Dent Clin N Am 48 (2004) 323–335 Box 1. In an oval. MinIWW at working length (MinIWW0) may be the same as MaxIWW at working length (MaxIWW0). long-oval. or flat canal as shown in Box 2. in a maxillary cuspid. For example.326 Y. the maximal initial horizontal dimensions (MaxIWW) may be several times larger than the minimal initial dimension (MinIWW) at different levels of the canal. This is because at that .

After root canal instrumentation.15]. Current descriptions of the horizontal dimensions (cross-sections) of the root canal 1. These are the length of the canal. the prevalence is greater than 50% [9]. the minimal final horizontal dimension at working length (MinFWW0) may be no different than the maximal final horizontal dimension at the working length (MaxFWW0) if there was not significant transportation. Round (circular): MaxIWW equals MinIWW 2. Determination of initial working width at working length (initial apical file determination—estimation of initial canal diameter) In the course of cleaning and shaping the root canal system. At the level of 5 mm from the working length in human teeth. it is common to have long-oval canals where the MaxIWW5 is two to four times greater than the MinIWW5 [9]. Flattened (flat. and the horizontal dimension of the preparation at its most apical extent. San Antonio. Recent studies suggest that the first K file and the first LightSpeed (LightSpeed Technology.13. also referred to as the initial apical file size. the clinician must determine three critical parameters. In general. the ratio between MinFWW12 and MaxFWW12 may be altered by the mechanical preparation of the canal. Texas) instrument that bound at the working length did not accurately reflect the diameter of the apical canal [10. the taper of the preparation. Jou et al / Dent Clin N Am 48 (2004) 323–335 327 Box 2. the master apical file size (MaxFWW0) is then suggested to be three International Standards Organization (ISO) file sizes larger than that initial binding file (Table 1).-T. the cross-section of a cuspid very often is a long-oval or flat canal shape. and in some groups of teeth. there is a 25% prevalence of long-oval canals in the apical third. At the level of 12 mm short of the working length. ribbon): MaxIWW is four or more times greater than MinIWW 5. In some textbooks. Oval: MaxIWW is greater than MinIWW (up to two times more) 3.Y. Long oval: MaxIWW is two or more times greater than MinIWW (up to four times more) 4. Irregular: cannot be defined by 1–4 level. Clinicians and researchers started to question whether the first file to bind corresponds to the apical diameter of the canal. One common method of deciding on the size of the apical preparation is to first determine the preoperative canal diameter by passing consecutively larger instruments to the working length until one binds. This initial apical file estimation is referred to as the determination of MinIWW0.11. however. The inaccuracy and discrepancy can come from various .

curvature of the canal. coronal interference. if not impossible. Other factors. Understanding these factors can minimize the underestimation of the IWW. Factors affecting the determination of minimal initial working width at working length Several factors may affect the accuracy of determining the MinIWW0. Canal shape The current descriptions of horizontal dimensions of the root canal system are listed in Box 2. curvature. canal content. and wall irregularities and the instrument used may all influence the result because each can affect the clinician’s tactile sense. The proper instrument and tactile sensation may determine the MinIWW of the oval. however.-T.328 Y. The combination of those factors makes correct determination of IWW very difficult. make determination of IWW difficult. The round canal can be measured more easily because the MinIWW and MaxIWW are the same. and the instrument used in estimating or measuring MinIWW0 and MaxIWW0. content. even in straight canals. canal length. taper. . The canal shape. Jou et al / Dent Clin N Am 48 (2004) 323–335 Table 1 Current concepts and guidelines determine the minimal final working width at working length from different publications Author and references Tooth Maxillary Centrals Laterals Canines First premolars Second premolars Molars MB/DB P Mandibular Centrals Laterals Canines First premolars Second premolars Molars MB/ML D Grossman [17] 80–90 70–80 60–60 30–40 50–55 30–55–50 40–50 40–50 50–55 30–40 50–55 30–55–50 Tronstad [20] Glickman and Dumsha [19] 70–90 60–80 50–70 35–90 35–90 35–60 25–40 30–50 25–40 25–40 35–60 80–100 25–40 25–50 35–70 35–70 50–70 35–70 35–70 25–40 25–40 30–50 30–50 30–50 35–45 40–80 25–40 25–50 Weine [21] 3 3 3 3 3 3 3 3 sizes sizes sizes sizes sizes sizes sizes sizes 3 3 3 3 3 3 3 3 sizes sizes sizes sizes sizes sizes sizes sizes morphologic and procedural factors such as canal shape. length.

bayonet-shaped) and with different degrees of severity. the longer the canal. and flat canals. The combination of these curvatures makes correct determination of IWW extremely difficult. It can eventually affect the clinician’s tactile sense. Early coronal flare can increase the taper of the canal and reduce the tapering discrepancy between the gauging instrument and canal wall. small radius. In addition. the mixed canal contents can create different degrees of frictional resistance against the gauging instrument. Canal content The content of the root canal may be fibrous in nature. then the shaft of the instrument may engage the canal wall and cause a false/premature conclusion as to the WW. The determination of MaxIWW. In a very long canal ([25 mm). denticles. the study by Wu et al [13] indicated that the first K file and the first LightSpeed instrument that bound at the working length failed to accurately reflect the diameter of the apical canal.-T. In curved mandibular premolars. and double curvature (S-shaped. The curvature of the root canal can be categorized into two-dimensional. however. three-dimensional. if not impossible. cannot easily be realized with current methods. Calcified material (calcific metamorphosis) may also be part of the canal content. The last 3 to 5 mm of the canal can have parallel walls.Y. if the coronal flare is too conservative or limited to the coronal third of the canal. causing a false sensation of apical binding. Canal length When using an instrument to gauge working length. making correct determination of IWW difficult. During determination of IWW. Canal curvature Curved canals can cause deflection of the gauging instrument and increase the frictional resistance. This factor makes correct determination of IWW somewhat more difficult. Each of these curvatures has a different effect on a clinician’s tactile sense. Canal wall irregularities Attached pulp stones. Jou et al / Dent Clin N Am 48 (2004) 323–335 329 long-oval. the frictional resistance may increase to affect the clinician’s tactile sense for determining the IWW correctly. Resorption can produce concavities . large radius. and reparative dentin can create convexities on the canal wall surface. Canal taper Any tapering discrepancy between the gauging instrument and canal may lead to an early instrument engagement of the canal wall. the greater the frictional resistance.

330

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on the canal wall surface. These phenomena can serve as an impacting factor
that induces a false estimation of the true canal dimension at working length
and other levels.
Instrument for determining initial working width
The rigidity, flexibility, and tapering of the instrument used for determining IWW can affect accuracy. As mentioned previously, any tapering
discrepancy between the gauging instrument and canal may lead to an early
instrument engagement of the canal wall, altering the tactile sensation. In
addition, the rigid instrument in a curved canal also can lead to a false
tactility. During IWW determination, the combination of those affecting
factors can have a great impact on the accuracy. Understanding these factors
can minimize the underestimation of the IWW and maximize its accuracy.

Eliminating or minimizing the influence of affecting factors
Being aware of the existence of the affecting factors in IWW determination
is the primary step in maximizing the accuracy of the technique. Without
knowing these factors, clinicians can repeatedly make the same mistakes in
underestimating IWW, which will lead to incomplete cleaning and shaping of
the root canal system as shown in Figs. 4–7.

Fig. 4. In a long-oval or flat root canal, reaming and modified reaming actions will result in
incomplete debridement of the root canal system. The ‘‘keyhole’’ and ‘‘dumbbell’’ effects (B,C)
are typical pictures that demonstrate the unprepared parts of the root canal. Most NiTi rotary
instruments used with continuous reaming and modified reaming actions like the balanced
force technique and quarter-turn pull technique will lead to the same misadventures (A–C).
Circumferential instrumentation can conform to the outline of the horizontal dimensions of the
root canal at different levels of the canal (D).

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331

Fig. 5. A cross-section of a NiTi rotary instrument–prepared canal indicates an incomplete
instrumentation. The untouched canal walls may lead to a failed root canal treatment.

Before the IWW determination, it is suggested to widen the orifices, to do
early coronal flaring and additional canal flaring (crown down, double
flaring) to ensure effective irrigation, and to minimize any interferences with
tactile sensation. Carefully selecting the adequate instrument of maximal
flexibility and minimal taper such as LightSpeed may avoid interference and
help to achieve better results.
Ideally, root canal preparation should follow the exact outline of the
horizontal dimensions of the root canal at every level of the canal. In this

Fig. 6. A cross-section of prepared and filled canals indicates an incomplete instrumentation
and may result in a failed root canal treatment. The ‘‘dumbbell’’ effects are typical pictures that
demonstrate the unprepared parts of the root canal. This misadventure can come from
underestimation of the IWW and the lack of understanding of endodontic WW concepts.

332

Y.-T. Jou et al / Dent Clin N Am 48 (2004) 323–335

Fig. 7. A cross-section of incompletely prepared and filled canals demonstrates the complicated
situation of endodontic WW. Understanding the concepts and the techniques of endodontic
WW can minimize misadventures of incomplete instrumentation and a failed root canal
treatment.

ideal condition, especially for long-oval and flattened root canals, they can
be cleaned and shaped properly with minimal mishaps of weakening,
stripping, or perforating the canal walls as shown in Fig. 4D. Circumferential preparation or instrumentation may have to be considered for these
cases to minimize incomplete cleaning of the root canal system. Most of the
NiTi rotary instruments provide a continuous reaming action that makes
the canal relatively circular in shape. Indiscriminate use of NiTi rotary
instruments alone for root canal cleaning and shaping may result in
incomplete cleaning of the root canal system and lead to failure of the
endodontic therapy (Fig. 5). Recent studies [10,12,14–16] have indicated
that no current instrumentation technique was able to completely clean
dentin walls of the oval, long-oval, and flattened root canals. The manual
crown down instrumentation technique, however, was more efficient and
effective in cleaning flattened root canals than rotary instrumentation.

Determination of the minimal and maximal final working width at
working length
To what extent the canal is supposed to be prepared has been a myth in
the endodontic field. Grossman [17] described the rules governing biomechanical instrumentation in his textbook Endodontic Practice. Among
them, he stated that the canal should be enlarged at least three sizes greater
than its original diameter. He gives four reasons to widen the canal space:
1. To remove bacteria and their substrates
2. To remove dead pulp tissue

Y.-T. Jou et al / Dent Clin N Am 48 (2004) 323–335

333

3. To increase the capacity of the root canal to retain a larger amount of
sterilizing agent
4. To prepare the tooth to receive the canal filling
These statements are reasonable; however, studies have suggested that
root canals have not been thoroughly cleaned even after being enlarged three
sizes greater than their original diameters. The concepts and techniques of
WW may play an important role in this finding. Any investigation of the
effectiveness of cleaning the root canal system without carefully estimating
the MinIWW and MaxIWW in the oval, long-oval, and flattened root canals
may result in misleading data, especially if the horizontal canal morphology
was not carefully assessed. In an oval, long-oval or flat canal, circumferential
instrumentation seems to be the only reasonable way to properly clean and
shape the canal. Especially in the infected canals, the infected dentin has to be
removed to ensure a successful treatment. Ideally, during root canal
preparation, the instruments and techniques used should always conform
to and retain the original shape of the canal to maximize the cleaning
effectiveness and minimize unnecessary weakening of tooth structure to
achieve the optimal result. It is very challenging to aggressively clean and
shape the infected canal without weakening the tooth structure. Clinically,
the heavily infected cervical part of the canal has often been enlarged with
Gates–Glidden burs or canal wideners to a round shape instead of following
the original oval, long-oval, or flat shape. Although the strength of the tooth
structure is evidently reduced [22], the FWW in the cervical area has been
determined by the clinician’s preference instead of scientific evidence. Based
on limited information [1,2,5–7,17–24] and reasonable concepts, several
guidelines were developed to determine the MinFWW0 (see Table 1). The
maximal discrepancy between the MaxFWW0 and MinFWW0 can be six to
eight ISO sizes. Complicated by canal curvature, the instrument used, and
the techniques implemented, the concepts for determining the MinFWW0
and MaxFWW0 seem unclear and chaotic. Between the cervical and apical
areas, the clinician has the absolute freedom to determine the MinFWW at N
mm from working length (MinFWWN) and MaxFWW at N mm from
working length (MaxFWWN) because the scientific information and
evidence are not yet available.
Most of the research for root canal instrumentation has not addressed
the importance of the horizontal dimensions or WW of the root canal
system. In preparing the long-oval or flat canals, the WW concept plays
a more critical role that alerts the operator to the possibilities of
incomplete root canal preparation. In vitro studies found that manual
circumferential filing had statistically significant better effectiveness than
rotary instrumentation for cleaning flattened root canals [14]. The concepts
of the WW indicate that different approaches and techniques are needed to
improve root canal preparation and promote better quality of root canal
treatment.

334

Y.-T. Jou et al / Dent Clin N Am 48 (2004) 323–335

Summary
There has been minimal development of concepts, techniques, and
technology to measure IWW and to determine FWW accurately or
properly. Understanding the current concepts and techniques of WW can
reduce the underestimation of the MinIWW0 and apical MinIWW and
subsequent incomplete cleaning of the root canal system. The detailed
information regarding horizontal morphology of the root canal system can
help to solidify concepts and improve techniques of cleaning and shaping
the root canal system. Carefully maintaining the aseptic chain, using
adequate irrigating solutions to enhance efficacy, and cautiously applying
current concepts and techniques of WW may provide a better quality of
endodontic therapy for the patient.
References
[1] Haga CS. Microscopic measurements of root canal preparations following instrumentation. J Br Endod Soc 1968;2:41.
[2] Gutierrez JH, Garcia J. Microscopic and macroscopic investigation on results of
mechanical preparation of root canals. Oral Surg 1968;25:108–16.
[3] Walton RE. Histological evaluation of different methods of enlarging pulp canal space.
J Endodon 1976;2:304–11.
[4] Mauger MJ, Schindler WG, Walker WA. An evaluation of canal morphology at different
levels of root resection in mandibular incisors. J Endodon 1998;24(10):607–9.
[5] Kerekes K, Tronstad L. Morphometric observations on the root canals of human molars.
J Endodon 1977;3(3):114–8.
[6] Kerekes K, Tronstad L. Morphometric observations on the root canals of human
premolars. J Endodon 1977;3(2):74–9.
[7] Kerekes K, Tronstad L. Morphometric observations on the root canals of human anterior
teeth. J Endodon 1977;3(1):24–9.
[8] Gani O, Visvisian C. Apical canal diameter in the first upper molar at various ages.
J Endodon 1999;25(10):689–91.
[9] Wu MK, Barkis D, Roris A, Wesselink PR. Prevalence and extent of long oval canals in
the apical third. Oral Surg 2000;89(6):739–43.
[10] Liu DT, Jou YT. A technique estimating apical constricture with K-files and NT
Lightspeed rotary instruments. J Endodon 1999;25(4):306.
[11] Levin JA, Liu DT, Jou YT. The accuracy of two clinical techniques to determine the size of
the apical foramen. J Endodon 1999;25(4):294.
[12] Weiger R, Lost C. Efficiency of hand and rotary instruments in shaping oval root canals.
J Endodon 2002;28(8):580–3.
[13] Wu MK, Barkis D, Roris A, Wesselink PR. Does the first file to bind correspond to the
diameter of the canal in the apical region? Int Endodon J 2002;35(3):264–6.
[14] Barbizam JVB, Fariniuk LF, Marchesan MA, Pecora JD, Sousa-Neto MD. Effectiveness
of manual and rotary instrumentation techniques for cleaning flattened root canals.
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[15] Tan BT, Messer HH. The quality of apical canal preparation using hand and rotary
instruments with specific criteria for enlargement based on initial file size. J Endodon 2002;
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[16] Wu MK, Wesselink PR. A primary observation on the preparation and obturation of oval
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[17] Grossman L. Endodontic practice. 10th ediiton. Philadelphia: Lea & Febiger; 1986.
[18] Dummer PMH, McGinn JH, Rees DG. The position and topography of the apical canal
constriction and apical foramen. Int Endo J 1984;17:192–8.
[19] Glickman GN, Dumsha TC. Problems in canal cleaning and shaping. In: Gutman L,
Dumsha C, Lovdahl, Hovland E, editors. Problem solving in endodontics. 3rd edition.
St Louis (MO): C.V. Mosby; 1997. p. 114.
[20] Tronstad L. Clinical endodontics. New York: Thieme; 1991.
[21] Weine FS. Endodontic therapy. 5th edition. St. Louis (MO): C.V. Mosby; 1996.
[22] Carter JM, Sorenson SE, Johnson RL, Teitelbaum RL, Levine MS. Punch shear testing of
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47. 265–267 0011-8532/04/$ . 313. 320 practice management software systems for. computers for. 50–51 suggestions for use of. as ‘‘hub’’ between office components. 316–317 Endodontic practice. 310.see front matter Ó 2004 Elsevier Inc. 37–38 accuracy of. 301–302 repair of root perforation and. 36–38 traditional-type. 321 E Electronic mailing. and retreatment. gaining access to. computers and. 317–318. 11–18 cleaning and shaping techniques in. 4–5. 311–312 digital radiography systems and. 317–318. design of.1016/S011-8532(04)00026-6 . 38–41. terminus of. 41–47 problems with using. 49 to detect root perforation. 48 use in primary teeth.’’ 309–321 Digital radiography systems. 35–54 frequency-dependent. 301–302 clinical cases illustrating. 300–302 calcium sulfate in. 316–317 technologies incorporated into. 266 Endodontic working width. 291–307 Apical foramen. 319. 295 in one-step apexification. 312–313 ‘‘endodontics-only’’ software for. All rights reserved. and microscope. 271–272 success of. 1–9 modern. extension of. failure of. 36–37 Apexification procedures. 316 for patient education. current concepts and techniques. doi:10. gaining access to root canal system in. 6–9 Endodontic therapy. access to. 291–293 Computers. 48 with additional functions. 267–271 reasons for. electronic. 1–9 anatomy of. 217 Collatape. 312 decision for. See Computers. modern. 321 documentation of treatment using. instruments and techniques for. A Apex locator(s). 311 for electronic mailing of reports and radiographic images. 323 conventional. 217 preparation of. 309 increasing knowledge base for users of. 303–306 mineral trioxide aggregate in. 38 history of. 311. 323–335 Endodontics. for hemostasis and barrier. factors influencing. for hemostasis and barrier. in root canal therapy. 309–310 D Dental office. 313. in root canal therapy. in ‘‘information age. one-step. 315 choosing software program for. 313 to manage vital information in practice. 291–293. 314–315.Dent Clin N Am 48 (2004) 337–339 Index Note: Page numbers of article titles are in boldface type. of reports and radiographic images. 309. 48 operation with various electrolytics. 319. 265–288 case selection for. obtaining information for. obturation of root canal system and. 301–302 Cavity. computers in. 275–286 C Calcium sulfate.

61–62 composition of. 197–199 series 29 sizes. 11–18 in nonsurgical endodontics. 219. 185–186 rules. 221–232 discussion of. 6 in one-step apexification. 148–156 assumptions for. for nonsurgical endodontics. 143–145 standard technique. 56 options and challenges in use of. 119 maintenance and replacement of. 113–135 instruments. description of. 19–34 for nonsurgical endodontics. 225–227 NiTiNOL alloy. 154–156 literature on. 199–201 hybrid sequences overview in. 218. 55. 220. 13 N Nickel. 231–232 I Instruments. 55. 137–157 author’s experience with. removal of. chronology of. 220. 117–118 description of. 280–286 ‘‘Endodontics-only’’ software. 18 endodontics and. 57 Nickel-titanium rotary instrumentation. manufacturing of. See ProTaper NT system. 56. 1–3. 13–14 K K3 rotary nickel-titanium file system. 224. of MicroSeal systems. 227–231 Gutta percha heater. 188–189 glide path for. 193 crown down. 128–130 MAR. 137. 221. 222. allergies to. 118–127 principles of. 218. 291. 59–64 Nickel-titanium (NiTi) alloy instruments. 223–225 preclinical test. 55 manufacturing of. 311 G Gutta percha. 57–58 NiTi ProTaper system. 190 working length determination in. 193–197 body shaping for. 15–17 NiTi alloy instruments. 204–207. corrosion and sterilization of. 275–280 solid material removal in. 223. 4 cost of. 55–67 use in endodontics. 197 ideal preparation. 218 Mineral trioxide aggregate. endodontic. 113–116 fracture of. 11–18 procedures requiring. 221. obturation of root canal system and. 232–253 technique in. 221. 231–232 modifications of. 5–6 common features of. 223–225 Nickel-titanium (NiTi). 190 M Microscope. 211 of MicroSeal systems. apical preparation for. 58–59 Nickel-titanium (NiTi) files. 185 step back. . 191–192 passive. nonsurgical ultrasonic. 130 IAR. 227–231 gutta percha heater. properties of. 119–122 technique of. 220. 217–264 condenser. 138–140 gauging of apex for. 221. variations on. 57–58 MicroSeal systems. design of. 232–235 obturation. 275–280 Gutta percha cones. 145–148 files. 295–296 Mouth mirror. 59 Nickel-titanium finger and engine spreader. 156–157 L LightSpeed System. 118. 224. 141–143 clinical technique. representatives of. 218. 183–202 limitations of. 237–246 nickel-titanium finger and engine spreader. 267 removal of semisolid materials in. 192–193 hybrid concept of. details of. 187 sample cases of. 224–231. and stainless steel. of MicroSeal systems.338 Index / Dent Clin N Am 48 (2004) 337–339 Endodontics (continued ) retreatment versus microsurgery. versus patient benefit of. 189–190 master apical file size in. 254–263 gutta percha cones. 189 straight line access for. 301–302 to seal perforations.

electronic apex locator to detect. 212–215 therapy of. 285 Tips. 91–94 finishing. 207. clinical performance of. 271–272 obturation of. 203. 99–108 shaping. 48 Rubber dam. 332–333 Root perforation. 5 System B unit. See Root canal system. 3–4 Ultrasonic tips. for irrigation in root canal therapy. 203. 328–330 minimal and maximal. 285 P Patient education. 217 Obturation instruments. 172–173 technique of. 73–76 sequences for use of. 330–332 factors affecting. cases illustrating. 163 speed of. 12–13 Post. See Ultrasonic tips. cavity preparation and. 28–33 vibratory. design of. cutting efficiency of. 11–12 S S-Kondensers. 309 Positioning. Thermafil. 203–215 cavity preparation and. 208. 296–300 one-step apexification procedures and. determination of. obturation of. 209 S-Kondensers and. perforation of. 101 file(s). 162–167 flexibility of. 327–328 eliminating or minimizing influence of affecting factors. 88–98 establishment of glide path with. of root canal system. 211 Obtura II unit and. in endodontic therapy. 204. 204. 159–182 file. 70–71 retreatment using. for nonsurgical endodontics. 203. 78. 100–101 design of instruments in. 272–274 ProFile system. 73 file. 204–207. 291 System B/‘‘Touch’n Heat. 203. 71–73 design of. calcium sulfate for hemostasis and barrier in. 24–27 bulk removal. 167–173 tip design in. 291–307 339 Root canal system. 203. 97–98 instrumentation with. 217 gutta percha cones and. obturation of root canal system and. 208. gaining access to. 217–219 Obturators. 95–97 irrigation and chelators used with.’’ 2. 175–176 Root. 291–293. 27–28 . 3–4. 166 quality of manufacturing. 295 collatape for hemostasis and barrier in. 102–103 torque-controlled endodontic motors. computers for. 171 resistance and torque requirements. 293–294 Sodium hypochlorite. 205. 164 pitch/helical angles of. 69–85 clinical applications and. facilitated removal of. 204 to treat impossible cases. 79 ProTaper NT system. U Ultrasonic instruments. 291–293 sodium hypochlorite for irrigation in. 20–23 access refinement. 324 at working length. 166–167. 204 T Thermafil obturators. ultrasonic. 79–80 safety concerns and. placement for nonsurgical endodontics. repair of. obturation of root canal system and. 293–294 System B unit and. 76–80 effect of chloride and sterilization on. 87–111 access cavity preparation with. determination of. 28 troughing. 173–175 for extrasmall canals. at working length. 291 working width of. 5 Obturation. 99–100 R Real World Endo Sequence File. 207. 165–166 rotary. 164–165 design of.Index / Dent Clin N Am 48 (2004) 337–339 O Obtura compactor.