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MODERN ENDODONTIC PRACTICE

CONTENTS

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

xi

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

NUMBER 1 JANUARY 2004

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.

Nickeltitanium: Options and Challenges


Michael A. Baumann

55

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

The ProFile System


Yeung-Yi Hsu and Syngcuk Kim

69

The ProFile instruments were among the first nickeltitanium


(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 Nickeltitanium File System


Richard E. Mounce

137

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

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 Nickeltitanium 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

vii

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

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


nickeltitanium (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
authors 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 techniques 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
widththe horizontal dimension of the root canal systemand
its clinical implications.

Index
CONTENTS

337
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Dent Clin N Am 48 (2004) xixii

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 le 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 eort. Many of these Penn Endo
graduates, who contributed signicantly to the advancements while at Penn,
are now teaching and practicing in dierent parts of the world and have
shared their ideas, experiences, and philosophies generously for this issue.
They are not only experts in their eld in their countries but many are also
pioneers in this changing eld. For that, this editor is extremely grateful.
The rst article describes the way modern endodontics is practiced in an
endodontic specialty practice, briey touching on the subject matter of each
article. In subsequent articles, the authors discuss the new generation of
instruments and new techniques in signicant detail so that the readers can
develop a working understanding of the techniques. The clinical benets of
the new treatment modalities far exceed our expectations. Cases are completed with greater precision, in less time, and with far fewer are-ups
between visits. It is the rare patient who experiences discomfort or clinical
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.005

xii

S. Kim / Dent Clin N Am 48 (2004) xixii

complications. Twenty-rst century endodontics is no longer the most


dreaded experience anyone can imagine, but mostly a pain-free, ecient
procedure with a predictably successful outcome.
I hope that readers share our excitement about the truly new and
improved endodontics and our commitment to its practice.
I would like to thank Mrs. Jutta Dorscher-Kim at the University of
Pennsylvania for her invaluable assistance in editing and Mr. John Vassallo
of W.B. Saunders Company for initiating this project and for his patience
and support.
Syngcuk Kim, DDS, MPhil, PhD, MD (hon)
Department of Endodontics
School of Dental Medicine
University of Pennsylvania
240 South 40th Street
Philadelphia PA 19104-6030, USA
E-mail address: syngcuk@pobox.upenn.edu

Dent Clin N Am 48 (2004) 19

Modern endodontic practice: instruments


and techniques
Syngcuk Kim, DDS, MPhil, PhD, MD(hon)
Department of Endodontics, School of Dental Medicine, University of Pennsylvania,
240 South 40th Street, Philadelphia, PA 19104-6030, USA

The specialty of endodontics has evolved and changed over the years like
many other dental and medical specialties. The changes that have occurred
in the last 10 years, however, have been of great magnitude and profundity.
The microscope, ultrasonic units with specially congured tips, superbly
accurate microchip computerized apex locators, exible nickel-titanium les
in rotary engines, and greater emphasis on microscopic endodontic surgery
have totally changed the way endodontics and endodontic surgery are
practiced. Comparing these changes with formocreosol medication, K-le
and radiographic determination of working length are truly dramatic. These
changes are bringing the specialty of endodontic practice into the twentyrst century with greater precision, fewer procedural errors, less discomfort
to the patient, and faster case completions.
Seven key advancements in endodontics were made in the last decade. Indepth discussion of each of these advancements is found in articles elsewhere
in this issue. In this article, the advancements and their applicability to
everyday practice are discussed (Fig. 1).

The microscope
The previous issue of the Dental Clinics of North America was devoted to
the use and advantages of the microscope. Briey, the microscope provides
great magnication and illumination and functions as an extension of loupes
(Fig. 2). The proper use of the microscope in endodontic therapy provides
an advantage over any other tools. The question of why we need loupes
or microscopes can be answered quite simply: loupes provide 2 to 4
magnication. Although small, this magnication has such an impact that
E-mail address: syngcuk@pobox.upenn.edu
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.002

S. Kim / Dent Clin N Am 48 (2004) 19

Fig. 1. Key instruments for the modern practice. (A) Electronic apex locator. (B) Nickeltitanium rotary ProFiles. (C) System B. (D) Spartan Piezo ultrasonic instrument. (E ) Obtura II.

Fig. 2. The bright focused light and high magnication provided by the microscope results in
endodontics of the highest, most accomplished level.

S. Kim / Dent Clin N Am 48 (2004) 19

Fig. 3. A completely instrumented madibular rst molar at 4 magnication (A). The same
tooth at 24 magnication (B) that shows dentin covering the pulpal oor. After removal of the
dentin, another canal is located and instrumented (C).

anyone who is used to loupes cannot practice without them. The microscope
provides 4 to 25 magnication. The questions here are, Do we need
magnication that great? and, in extension, What is the optimum
magnication for endodontic procedures? In the authors opinion, the optimum magnication for endodontic practice ranges from 8 to 24 magnication (Fig. 3). The high magnication is needed to locate hidden canals,
detect microfractures, distinguish between the chamber oor and dentin, and
identify isthmuses and other small anatomic entities, of which recognition
and treatment are so important for endodontic therapy success.
In conventional endodontics, the microscope is most useful for locating
canals after the access is made. It is extremely useful for post removal using
ultrasonic instruments and for perforation repair. These are procedures that
previously were done largely by feel. The advent of the microscope in
modern endodontic therapy facilitates a primarily visually guided, secondarily sensory-aided endodontic procedure (Fig. 4).

Ultrasonic instruments
There are two types of ultrasonic tips on the market: surgical and
nonsurgical.
Surgical tips are for root canal retropreparation, and there are many types
available (see the Obtura/Spartan Company Web site, Fenton, Misssouri).
Nonsurgical tips come in two categories. First, the Buc tip is used for
conventional cases such as cleaning the chamber so that endodontists can
visualize the chamber without dentin debris (see the article by Kim elsewhere

S. Kim / Dent Clin N Am 48 (2004) 19

Fig. 4. The microscope is best used for repair of perforation (A), identication or detection of
microfractures (B), and removal of posts and/or separated les (C).

in this issue, [Fig. 8]). The sharp-ended tips allow clinicians to pick and
explore the chamber oor to identify canals. This ultrasonic instrument is
a lifesaver when calcied canals are encountered. High- or low-speed burs are
much too large to catch the minute, sometimes microscopic, openings to
calcied canals. A second type of nonsurgical ultrasonic tip is the CPR tip.
These tips are used mainly for post removal. Although posts can be removed
with burs, even the smallest burs unnecessarily remove large amounts of
dentin compared with CPR tips. Over 90% of the post can be removed by
CPR tips driven by a Piezo ultrasonic instrument, with much less gouging or
damaging the dentin structure around the post than with burs.
Cleaning the pulp chamber is also an important prerequisite for inspection
of the chamber for anatomic details. This cleaning can be done best with
a diamond-coated small microburner tip (eg, Buc tip size 2). Microscopic
observation is not eective when the chamber oor is full of dentin debris
that is created by burs.

Electronic apex locator


If asked what the most important advancement in endodontics in the
recent decade is, the authors unequivocal answer would be the electronic
apex locator (see Fig. 1A). After the microscope, the electronic apex locator
has become the most important and essential instrument in endodontic
practice. Advancements in microchip technology led to the design of a better
apex locator, making the radiographic determination of root canal length
nearly obsolete. The correct use of the locator always identies the root end

S. Kim / Dent Clin N Am 48 (2004) 19

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

S. Kim / Dent Clin N Am 48 (2004) 19

question is, Will NiTi le systems replace the stainless steel K-le system?
The answer is denitely not. The NiTi le systems are very convenient for
milling the canal but not for cutting the canal dentin. Cutting the dentin is
usually done with GatesGlidden burs or K les in combination with NiTi
rotary les. By using these instruments, the canals can be prepared more
easily and uniformly. Some clinicians avoid the NiTi rotary systems due to
breakage of the le tip inside of the canal. This breakage can be minimized
greatly by light-handed and careful use. The author considers the NiTi le
system not a must-have instrument, but rather a convenient instrument.
There are basically two types of NiTi systems: the LightSpeed (LightSpeed, San Antonio, Texas) and the non-LightSpeed types. The LightSpeed
type is a miniaturization of the GatesGlidden bur, with a 0.02-type handle
with varying le tip diameters. The non-LightSpeed types include active
systems with a positive rake angle that cut the dentin, and others that are
passive with a negative rake angle that mill the dentin. For instance, the
most popular type is the ProFile (Dentsply, Tulsa, Oklahoma) with a
negative rake angle. Each of these systems oers les ranging from 0.02 to
0.12 taper with smaller tip diameters.
Although there are many pitfalls on the road to consistent results, with
proper use of the NiTi systems, endodontists will be able to improve the
quality and esthetics of their endodontic obturations quickly.
Mineral trioxide aggregate
Mineral trioxide aggregate (MTA) is a reliable new endodontic material
initially designed as a retrolling material. More recently, it also has been
advocated for pulp capping, perforation repair, and even as an endodontic
lling material for apexication. MTA is a mixture of many oxides and looks
like grayish-brown sand. In fact, it handles like sand and some clinicians have
compared it to Portland Cement. In a moist environment, it sets in about 7
hours. In conventional endodontics, it has proved to be the best material for
most types of perforation. Its unique physical property is its compatibility
with bone. It has been shown in numerous studies and in clinical practice that
it is the only material into which bone and cementum cells actually grow,
thereby creating a perfect seal and an ideal barrier. This is a material that has
long been on the endodontic wish list because perforations during endodontic procedures or during post preparation are not that uncommon.

Anatomy of modern endodontic practice


Excellent and consistent endodontic outcomes are still very dicult to
obtain. With the incorporation of the new generation instruments, along
with a thorough knowledge of the root canal anatomy and endodontic
practice, however, far better and more consistent results can be obtained

S. Kim / Dent Clin N Am 48 (2004) 19

Fig. 5. At high magnication, a fourth canal (MB2) of a maxillary rst molar can easily be
detected (A) and is shown with a size 10 le in the canal entrance (B). (Courtesy of F. Maggiore,
DDS, Rome, Italy.)

than in the past. To illustrate the modern endodontic procedural sequence


of a normal case of a maxillary rst molar, an itemized sequence follows:
1. The diagnosis indicates that endodontic treatment is needed and the
tooth is anesthetized.
2. Following placement of the rubber dam, access is made. The microscope
is not needed for this step, although some clinicians may prefer to use it.
3. Using the microscope at low to mid magnication, the pulp chamber is
thoroughly prepared using a Buc tip size 2 for inspection.
4. Under high magnication (1624), the oor of the chamber is
examined for additional canals because more than 50% of molar teeth
have a fourth canal (Fig. 5).
5. After the canal entrance is identied, the microscope is not needed until
a later stage. The apex is negotiated with a size 10 K le and is then
enlarged with size 15 or 20 les.
6. GatesGlidden burs are used in reverse order to enlarge the coronal one
half or two thirds using the crown down technique. During this enlargement, it is important to use irrigants (2.5%5% sodium hypochlorite and
17% EDTA solution) to penetrate deep into the canals.
7. An apex locator is used to determine the canal length at this stage. In
this manner, a more accurate canal length measurement is possible
because coronal interference has been eliminated.
8. NiTi rotary instruments are now employed to prepare the remaining one
half or one third of the apical canal in the crown down manner. The
nal apical preparation or determination of the master apical le is done
by hand instruments or LightSpeed, depending on the original canal
width or estimate of working width.
9. 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. 6).
10. A master gutta percha cone is selected; the canal length and solid tug
back is assured.

S. Kim / Dent Clin N Am 48 (2004) 19

Fig. 6. Radiograph of the maxillary rst molar prior to endodontic therapy (A) and microscopic examination of the prepared four canals at 24 magnication of the same tooth (B).

11. This master cone, coated with root canal cement, is inserted into the
canal, and the coronal part of the point is seared o using System B. The
gutta percha in the apical 3 to 4 mm is packed with S-Kondensers.
12. The Obtura gutta percha compactor with an appropriate tip is inserted
into the canal up to where the master gutta percha was seared o. The
thermoplastesized gutta percha lls the canal as the tip is slowly
withdrawn.
13. The microsocpe is used again for a nal check. Finally, the canal is
sealed with temporary cement.
This brief sequence shows the use of modern endodontic instruments.
The purpose of incorporating these advanced instruments is to perform
endodontic procedures more accurately, thus experiencing less postoperative discomfort, fewer procedural errors, and a more ecient procedure.
Although the ultimate criteria (ie, whether the incorporation of these

Fig. 7. Multicanal cases done by endodontic graduate students at the University of


Pennsylvania using the modern instruments and techniques described in this article.

S. Kim / Dent Clin N Am 48 (2004) 19

instruments provides greater treatment results and success) has still not been
established in a formal study, the authors clinical experience of the last 10
years has shown that the procedures are more predictable, ecient, and
reliable, and result in fewer are-ups and less discomfort for patients. In
addition, the radiographic results are far better, with a signicant increase of
over 40% in locating fourth canals in molars (Fig. 7). These improvements
are truly signicant.

Dent Clin N Am 48 (2004) 1118

The microscope and endodontics


Syngcuk Kim, DDS, MPhil, PhD, MD(hon)a,*,
Seungho Baek, DDS, PhDb
a

Department of Endodontics, School of Dental Medicine, University of Pennsylvania,


240 South 40th Street, Philadelphia, PA 19104-6030, USA
b
Department of Conservative Dentistry, Seoul National University, Seoul, Korea

It may seem surprising that the microscope is not a high-tech instrument.


It has been used in the medical eld for over 50 years. According to the Zeiss
Company, the microscope was rst introduced to otolaryngology around
1950, then to neurosurgery in the 1960s, and to endodontics in the early
1990s. Dentistry, therefore, is about 40 years behind medicine in this respect.
As in medicine, the incorporation of the microscope in clinical endodontics
has had profound eects on the way endodontics is done and has changed
the eld fundamentally. For this reason, 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. This was a giant step forward in the
advancement of endodontics.
This article outlines the key prerequisites for the use of the microscope in
nonsurgical endodontic procedures. There are many microscopes on the
market; the three most popular ones are presented in Fig. 1.
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. This technique is taught at all
dental schools. In endodontics, however, the purpose is greater. Here, the
rubber dam placement is necessary because direct viewing through the canal
with the microscope is dicult, if not impossible. A mirror is needed to reect
the canal view that is illuminated by the focused light and magnied by the lens
of the microscope. If the mirror were used for this purpose without a rubber
* Corresponding author.
E-mail address: syngcuk@pobox.upenn.edu
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.001

12

S. Kim, S. Baek / Dent Clin N Am 48 (2004) 1118

Fig. 1. The three most popular microscopes in endodontics.

dam, then the mirror would fog immediately from the exhalation of the
patient. Thus, the powerful microscope magnication and illumination would
be rendered totally useless for the necessary visualization of the chamber oor
and the canal anatomy. To absorb reected bright light and to accentuate the
tooth structure, it is recommended to use blue or green rubber dams (Fig. 2).

Fig. 2. The use of a rubber dam is essential for eective microscope use.

S. Kim, S. Baek / Dent Clin N Am 48 (2004) 1118

13

Indirect view and patient head position


As mentioned previously, it is nearly impossible to view the pulp
chamber directly under the microscope. Instead, the view seen through the
microscope lens is a view reected by way of a mirror. To maximize
the access and quality of the view by this indirect means, the position of the
patient (especially the head position) is important (Fig. 3). The optimum
angle between the microscope and the mirror is 45 , and the clinician should
be able to obtain this angle without requiring the patient to assume an
uncomfortable position. The maxillary arch is rather easy for indirect
viewing. Basically, the patients head is adjusted to create a 90 angle
between the maxillary arch and the binocular (Fig. 4). In this position, the
mirror placement will be close to 45 for best viewing.
Mouth mirror placement
It is always a good idea to use the best mirror for this purpose. If a rubber
dam has been placed, then the mirror must be placed away from the tooth
within the connes of the rubber dam. If the mirror is placed close to the
tooth, then it will be dicult to use other endodontic instruments. Readjusting the mirror will necessitate refocusing of the microscope, making the
entire operation time-consuming and, at times, frustrating. This is especially
true during a lengthy perforation repair. With practice, however, the
correct placement of the mirror will become automatic.
Some key instruments
The ability to locate hidden canals is the most important and signicant
benet gained from using the microscope. To do this eectively and eciently,
clinicians must use specially designed microinstruments. An explorer can pick
the entrance of a canal under the microscope, but negotiating the canal with

Fig. 3. Patients should wear protective dark glasses and have support for the neck, such as
a moldable pillow.

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S. Kim, S. Baek / Dent Clin N Am 48 (2004) 1118

Fig. 4. Positioning the microscope. Notice the ergonomics of the clinician and comfortable
patient position.

a le can be challenging because there is only a tiny space between the mirror
and the tooth for a nger with a le to move around. Files specially designed
by Maileer, called microopeners, have with dierent sized tips and can be
extremely useful (Fig. 5). These hand-held les allow the clinician to initially
negotiate the canal, verifying that the catch is truly a canal. After the canal
is located in this manner, clinicians can instrument the canal normally without
the microscope. The use of GatesGlidden burs to enlarge the canal entrance
prior to full instrumentation, however, can be easily achieved under the
microscope, facilitating the subsequent steps of canal instrumentation.

Fig. 5. Micro-openers by Maillefer are ideal instruments for exploration of hidden canals at
high magnication.

S. Kim, S. Baek / Dent Clin N Am 48 (2004) 1118

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. This may a noble idea, but in reality, it
is not needed or desired. A clinician must consider the benet/risk ratio
when using the microscope. The following procedures are those that benet
from the use of the microscope.
Diagnosis
The microscope is an excellent instrument to detect microfractures
that cannot be seen by the naked eye or by loupes. Under 16 to 24
magnication and focused light, any microfracture can be easily detected
(Fig. 6). Methylene blue staining of the microfracture area assists this eort
greatly.
A persistently painful tooth after endodontic therapy may be due to an
untreated missing canal (eg, MB2 in a maxillary molar). Re-examination of
the chamber at high magnication under the microscope may locate the
missing canal (see the article by Kim elsewhere in this issue [Fig. 5]). It has
been the authors 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.
Locating hidden canals
As discussed in many sections in this issue, the most important utility of
the microscope in nonsurgical endodontics is locating hidden canals. The
canal anatomy is extremely complex. All endodontic textbooks have
information on molar teeth with three canals, premolars with two canals,
and anterior teeth with one canal. Often, dental anatomy is not that
predictable. Following the introduction of the microscope to the Graduate
Endodontic Program at the University of Pennsylvania in 1992, it has been

Fig. 6. Microfracture detected under the microscope (A) and the same tooth after extraction
(B). Arrows identify the fracture line.

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S. Kim, S. Baek / Dent Clin N Am 48 (2004) 1118

found that nearly an astounding 50% of all molars (maxillary and


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

Fig. 7. Buc tips (Obtura/Spartan) are ideal ultrasonic instruments for cleaning the pulp
chamber and oor for clear viewing of the canals.

S. Kim, S. Baek / Dent Clin N Am 48 (2004) 1118

17

Fig. 8. Access preparation and management of calcied canals at a high magnication under
the microscope (AF ). (Courtesy of F. Maggiore, DDS, Rome, Italy)

perforation repair will be made (see the article by Kratchman elsewhere in


this issue). Briey, the microscopic procedure is to place a matrix precisely,
just outside of the perforation site (ie, just exterior of the root substance).
The matrix can be calcium sulfate or resorbable collagen. After the matrix is
placed, mineral trioxide aggregate is packed against the matrix. This
procedure requires delicate and careful handling of the materials so as not to
extrude, overll, or underll. The microscope is essential for this procedure.
Retrieval of broken les
With the more frequent use of nickel-titanium rotary les in general
dentistry, the incidence of le separation within the canals has increased.
When the le is broken at the apex, the microscope cannot be of help. If
the le breaks within the coronal half of the canal, however, then the
microscope is essential to guide the clinician to retrieve the broken les. In
this manner, the broken le can be removed while minimizing the damage to
the surrounding dentin.
Final examination of the canal preparation
It takes a simple step to see whether a canal is completely cleaned. Under
the microscope, a small amount of sodium hypochlorite, a popular irrigation solution, is deposited into the canal and observed carefully at high
magnication. If there are bubbles coming from the prepared canal, then
there is still remnant pulp tissue in the canal. In short, the canal needs more
cleaning.

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S. Kim, S. Baek / Dent Clin N Am 48 (2004) 1118

Cost versus patient benet


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

Dent Clin N Am 48 (2004) 1934

Nonsurgical ultrasonic
endodontic instruments
Mian K. Iqbal, BDS, DMD, MS
Department of Endodontics, The Robert Schattner Center, University of Pennsylvania,
School of Dental Medicine, 240 South 40th Street, Philadelphia, PA 19104-6030, USA

One of the most important advancements in endodontics has been the use
of the surgical operating microscope, which in turn necessitated the
evolution of a number of microendodontic instruments. Among these,
ultrasonic instruments have improved the most. Ultrasonic technology has
been available for a long time [1]; the only thing needed to make a modernday ultrasonic instrument was incorporation of a contra-angle bend and
parallel working ends. The contra-angle design allowed for dramatic
improvement in procedural access for both anterior and posterior teeth,
in addition to an unobtrusive view under the microscope.
Ultrasonic instruments play an ever-increasing role in several aspects of
endodontic treatment. Teeth with root canal obstructions are no longer automatically treatment planned for surgical endodontics; endodontic retreatment has become the procedure of choice. In addition, root canal obstructions
are being removed in a more conservative manner that does not unnecessarily
destroy the root structure. The identication of missed and hidden canals has
become a predictable outcome rather than a serendipitous discovery. Access
cavities are being cut and rened with greater precision, opening up gateways
to better endodontics. Above all, these procedures are no longer being
performed blindly; instead the clinician is now able to maintain visual contact
with the operating eld at all times during ultrasonic procedures.
The ultrasonic technique is essentially a nonrotary method of cutting
dental hard tissue and restorative materials using piezo-electric oscillations.
Cutting dentine structure with ultrasonic tips is analogous to cutting dentine
with the thinnest bur imaginable. Because the operating eld is so restricted,
the use of high magnication and proper illumination is essential during the
use of these instruments. The combination of ultrasonic instruments with the

E-mail address: miqbal@pobox.upenn.edu


0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.10.001

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M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

magnication and illumination provided by surgical operating microscope


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

M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

21

Fig. 1. Two tips from the Osada Enac ultrasonic endodontic system. The ST21, shown at the top,
is used for removing solids from root canals. The bottom picture shows the vibratory tip ST09.

Breakage of ultrasonic tips is a common phenomenon. Once broken, these


tips usually jump out of the canal or can be retrieved easily. However, some
of these tips are quite expensive and must be used properly to avoid
unnecessary breakage. The most common reason that tips break is because

Fig. 2. Retreatment CPR tips 2D through 5D are diamond coated with built-in water ports that
allow for wet or dry cutting.

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M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

Fig. 3. Titanium CPR ultrasonic tips 6 through 8.

they are not operated at their recommended frequencies. Therefore, it is


important to follow the manufacturers recommendations with regard to the
ultrasonic intensity at which a particular tip must be used. The results of
a recent study [2] revealed a signicant increase in displacement amplitude

Fig. 4. BUC access renement tips 1 through 3.

M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

23

Fig. 5. The 4 series is specially geared toward post removal.

and depth of dentine cut with an increase in power setting. However, the
slender and longer tips with small cross-sectional diameters (ie, CPR 68) will
fracture easily when used at high intensity. On the other hand, short and
sturdy tips used for vibrating posts out of root canals are operated at
medium-high intensity. Similarly, tips that are used for bulk removal of
dentine or restorative materials (eg, CPR 2) also need to be used at moderate
to high intensities. The troughing tips (eg, CPR 3D5D, BUC 3, and CPR 6
8) should be used at low intensity. In general, thick and short tips are
operated at higher intensities, whereas long and slender tips are operated at
lower intensities.
Tips with bends increase access to dierent parts of the mouth; however,
excessive angulations also make these tips more vulnerable to breakage [3].
In addition, tips that are designed primarily for cutting dentine can break

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M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

easily if inadvertently brought into contact with metals. The shanks of


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

M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

25

action can be observed directly and continuously under the microscope. The
size of ultrasonic tips is smaller than the smallest burs; therefore, the dentine
can be brushed o in smaller increments and with greater control. The
process allows for exposure of any missed or hidden canals or recesses
containing necrotic pulp tissue without gutting down the tooth structure
(Fig. 6). The process is similar to archeologists unearthing artifacts at
excavation sites. The dentine must be brushed o in smaller increments until
the road map on the oor of the pulp chamber is uncovered completely. The
usual term used for this procedure is unroong the pulp chamber;
however, this term is valid only when dealing with young and large pulp
chambers. For pulp chambers that have receded with calcication, the term
uncovering the oor of the pulp chamber is more appropriate.
Another advantage of ultrasonic instruments over burs is the production of
cavitation within the cooling water that ows over the tip of the ultrasonic
instrument [4]. Cavitation may be described simply as bubble activity in
a liquid, which is capable of generating enough shock waves to cause
disruption of remnants of necrotic pulp tissue and any calcic deposits.
Therefore, it is no wonder that access cavities prepared with ultrasonic
instruments have a thoroughly washed out and clean appearance (see Fig. 6B).
A number of tips are available to rene the access cavity. The uncovering of the oor of the pulp chamber can be accomplished with the help of
the CPR 2D or BUC 1 tips. If the dark, colored oor of the pulp chamber is
not visible, it usually is obscured by pulp stones or tertiary dentine deposits
(Fig. 7). The pulp stones sometimes can be vibrated or teased out by the
CPR 2D or BUC 1 tips (see Fig. 7A); at other times, they can be planed with
the help of a BUC 2 tipa process similar to planing the root surface. The
tip of this instrument is designed with a planed surface and it can grind the
oor until the dark-colored dentine becomes visible. The unveiling of
the dark-colored oor of the pulp chamber is of critical importance because
it dictates and guides the extension of access cavity.

Fig. 6. (A) Mandibular molar requiring retreatment shows presence of gutta-percha in two
mesial and one distal canal. The remaining chamber contained remnants of sealer cement and
necrotic tissue. (B) Removal of gutta-percha lling and use of ultrasonic instruments exhibits
debridement of the chamber and the presence of an untreated fourth distal canal.

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M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

Fig. 7. (A) An ultrasonic tip is being used to remove heavy calcic deposits on the oor of
a maxillary molar pulp chamber. (B) The use of ultrasonic energy led to shattering of pulp
stone. (C) This picture reveals the presence of four root canal orices, but the absence of any
pulpal oor road map. (D) Continued removal of calcication and renement of access cavity
with ultrasonic instruments exposes the oor of the pulp chamber and the presence of an
additional distobuccal canal. (Courtesy of Dr. Helmut Walsch, Munich, Germany.)

The second mesiobuccal canal (MB2) is reported to occur in more than


90% of maxillary molars [5]. On average, it is located 1.8 mm away from the
mesiobuccal canal in a palatomesial direction. A protocol involving
deepening of the bucco-lingual groove overlying the mesiobuccal root is
essential for locating the MB2 [6]. The groove should not be extended
toward the palatal canal but rather in a direction slightly mesial to it, so as
to follow the bucco-lingual orientation of the mesiobuccal root. The rening
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.
The rening tips also are used for moving the mesial marginal ridges
mesially to have a direct line access to the MB2 canal [7]. In addition, the
tips also can be used for delineating the outlines of the root canal orices so
that the overhanging dentine deposits are removed and the orices are
exposed. This step sometimes can reveal the presence of two canals in
a single orice and helps to guide the instruments easily in and out of the
canals. The ultrasonic tips can be used to dig and follow the sclerosed canals
until patency is achieved. However, this procedure must be accomplished by
a number of radiographic checks and restricted to the coronal aspect of the

M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

27

root trunk only. To check progress, an ultrasonic tip is used to dig a test
hole at the most probable site of the sclerosed canal. The test site is lled
with thermoplastisized gutta-percha and an orientation radiograph is
exposed (Fig. 8). If the test site is found centered in the root and pointing
correctly, then cutting is continued to enter the canal; otherwise, the
direction of the cutting is modied according to information gathered from
the radiograph. Radiographs are two dimensional in nature, however, and
do not provide any information regarding the bucco-lingual depth of the
tooth structure.
Vibratory tips
Removal of intraradicular posts has always been a challenge when
performing endodontic retreatment. This procedure also has been fraught
with unwanted consequences, such as root fracture or perforation. The
implementation of ultrasonic energy has provided the clinician with an important adjunctive method for removal of posts. A number of studies [811]
have shown conclusively that the use of ultrasonic vibration signicantly
reduces the amount of tensile force required to dislodge both the cast and
prefabricated posts. The VT (Sybron Endo), Osada Enac ST09, and CPR 1
are examples of such instrument tips. The tips of these instruments are
spherical or at and are placed against the post to transmit vibration. They

Fig. 8. A check radiograph of a calcied central incisor showing an ultrasonically prepared test
site lled with radiopaque gutta-percha. The ultrasonic tip was not aligned parallel to the long
axis of the tooth and needed to be redirected to avoid root perforation.

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M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

are activated at the maximum intensity and moved circumferentially until


the post loosens or dislodges. If this method does not loosen and free the
post then alternate methods must be used. The manufacturer cautions
against placing these tips directly on ceramics because it may cause severe
damage to the prosthesis.
The inability to remove posts by vibration alone is dependent on many
factors such as the type of luting agent, the length and type of the post, and
the type of core buildup. The core buildup around the post should be
removed before applying the vibratory tip. In some cases, the troughing tip
should be used around the post and then vibratory tips should be reapplied to
obtain the maximum benet. Posts luted with zinc phosphate cement can be
dislodged readily by ultrasonics because of microcrack formation in the
cement [12]. However, posts luted with resin cements such as Panavia fail to
dislodge by ultrasonic vibration, probably due to the lack of the microfracture propagation in these materials [12].

Bulk removal tips


Bulk removal tips are extremely sharp and sturdy tips that are operated at
moderate or maximum intensity of the ultrasonic unit. BUC 1 and CPR 2D
are examples of tips that fall into this category. 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.
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. In retreating cast post and cores, the
core portion is reduced and sculpted until it becomes an extension of the
post itself [13]. This gives the clinician a purchase point to apply extraction
devices when normal vibratory motions fail to dislodge the post completely.
The controlled and incremental cutting with ultrasonic instruments under
magnication provides a clear contrast between the core materialsfor
example, between composites and the underlying dentinal structure.
Therefore, the chances of inadvertently perforating the crown of a tooth
are reduced greatly.

Troughing tips
Troughing tips are used to create a suciently deep trough around posts
to maximize the benets of subsequently applied vibratory or extraction
forces. In the past, troughing around the root canal obstruction was performed with trephine drills. This process was extremely destructive and frequently led to the gutting down and perforation of root trunks. Now with
the help of ultrasonic tips, troughing around root canal obstructions can be
performed in a predictable and controlled manner.

M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

29

Fig. 9. The initial troughing around a post can be performed with shorter tips such as diamondcoated CPR 2D or 3D. (Courtesy of Dr. Samuel Kratchman, Exton, PA.)

Initially, the troughing is performed with instruments such as CPR 3D,


4D, and 5D, which are 15, 20, and 25 mm in length, respectively (Fig. 9).
These instruments are used in the coronal, middle, and apical one third of
root canals and their selection depends on the depth at which they need to
be operated. These instruments are diamond coated and aggressively cut
dentin along their lateral sides. The BUC 3 (Obtura/Spartan, Fenton, Ohio)
or CT 4 tip (Sybron Endo), which also is available with a diamond coating,
can be used for this purpose. The instruments not only remove cement that
may be present around the post, but also remove a thin shelf of dentine
around the perimeter of an obstruction.
If the obstruction is located in the deeper part of a straight canal, then
titanium CPR tips 6 (red), 7 (blue), and 8 (green) are used, which are 20, 24,
and 27 mm long, respectively. These instruments are quite slender, long, and
parallel sided to cut deep into the root without taking away too much
dentine, and at the same time provide maximum visibility under the
microscope (Fig. 10). These instruments are especially useful when removing
long and thick prefabricated post systems (Fig. 11). The fact that these

Fig. 10. (A) CPR 6 is being used to trough between the post and the lingual wall of the root
canal. (B) View of the trough produced around the lingual aspect of the post with the help of
ultrasonic les.

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M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

Fig. 11. (A) Radiograph showing the presence of a long, threaded post associated with a failing
root canal treatment. (B) Radiograph showing completion of root canal treatment after
removal of the threaded post.

instruments are made of titanium alloys and have thin cross-sectional


diameters makes them extremely exible and vibrant, but, at the same time,
subject to breakage. The instruments should be used with a light touch; that
is, with the same amount of pressure used to avoid breaking the lead tip of
a pencil. These tips most commonly fracture when inadvertently brought
into contact with metallic objects such as posts. Therefore, extreme caution
needs to be taken when using these instruments. The instruments must be
used at low intensities and always under the magnication provided by the
microscope so as to not inadvertently contact any metallic obstruction.
Unlike CPR tips 3D, 4D, and 5D, which are diamond coated and active
along the sides of their tips, CPR tips 6, 7, and 8 are end cutting and only
active at their tips. Therefore, before troughing with these tips a collar of
dentine must be exposed around obstructions that are embedded in root
canals. The collar or shelf of dentine can be prepared around the
obstructions with the help of LightSpeed instruments (LightSpeed, Inc.,
San Antonio, Texas). The tips of these instruments are attened with the
help of a grinding stone (Fig. 12), which allows them to cut dentine as close
to the obstruction as possible. The instruments are used sequentially to the
coronal extent of the obstruction until the canal is enlarged suciently, and
a shelf of dentine is prepared around the obstruction (Fig. 13). Gates
Glidden (GG) drills also can be used for this purpose; however, GG drills
can be used only in the straight portions of the canal and are unable to

M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

31

Fig. 12. Drawing showing LightSpeed instruments attened at their tips with the help of
a grinding stone.

negotiate any curvatures in the root canals [13]. Nevertheless, retreatment


becomes dicult 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. Once the shelf of dentine is prepared, CPR tips 6, 7,
and 8 can be used to create a trough around the instrument (see Fig. 13D).
The tips are moved counterclockwise around the fractured instrument to
disengage it from the surrounding dentine [14]. Once loosened, the
instrument usually moves coronally and jumps out from the root canal
(Fig. 14). In other instances, the exposed part of the separated instrument
can be grabbed and pulled out with one of the currently available extraction
devices.
The use of NiTi rotary instruments has increased the incidence of le
separation in endodontics. The NiTi les mainly break by either torsional
fracture or exural fatigue [15]. In the former case, the instrument usually
gets forced into the root canal and, once jammed, fractures at its weakest
point. This type of failure is associated most often with an unwinding of
utes that can be recognized under the operating microscope (Fig. 15A).
The fractured instruments usually are engaged into dentine along their
whole lengths and at times may be dicult to remove. On the other hand,
fatigue failure causes the instrument to fracture at the point of its maximum
exure. These instruments do not exhibit any unwinding of utes when
observed under the operating microscope (see Fig. 15B). Even though these
instruments are not tightly bound in dentine, they may be dicult to access
because their coronal ends usually are located apical to the elbow of root
curvature.
In addition to trephining around posts and removal of broken instruments and other intracanal obstructions, ultrasonic instrumentation also
can be used for eliminating brick-hard paste-type materials [16]. The
procedure can be accomplished with CPR 3D, 4D, and 5D; BUC 3; or ST21
Enac tips under the microscope so that the paste can be dierentiated easily

32

M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

Fig. 13. (A) Initially, a small-sized instrument is selected and carried down to the obstruction.
(B) Instruments are used sequentially to enlarge the root canal space. The arrow in the gure
points toward the approximation of a modied LightSpeed instrument and the root canal
obstruction. (C) The arrow in the gure points toward a shelf of dentine that has been created
around the separated instrument. (D ) The arrow indicates a trough created around the
separated instrument with the help of ultrasonic tips.

M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

33

Fig. 14. (A) Preoperative radiograph of a maxillary left rst premolar shows a separated
instrument in the palatal canal. (B) Postobturation radiograph. The instrument was removed
easily with ultrasonic vibration. (Courtesy of Dr. Bekir Karabucak, Philadelphia, PA.)

from the surrounding root canal dentine. Under the microscope, the
pastedepending on its colorappears as a white or pinkish dot. The CPR
tips are used to eliminate it by following the dot to its apical extent.
However, no attempt should be made to remove paste materials around
curves, because the ultrasonic les are unable to negotiate curvatures and
may lead to perforation of the root surface. Ultrasonic tips also can be used
to help MTA ow precisely into place. This is done by depositing mineral

Fig. 15. (A) Drawing of a NiTi instrument depicting unwinding of the utes associated with
a torsional failure. (B) In case of exure failure, no signs of unwinding of the utes can be noticed.

34

M.K. Iqbal / Dent Clin N Am 48 (2004) 1934

trioxide aggregate (MTA) at a site (ie, perforation) and then vibrating it


with an activated ultrasonic tip until it ows evenly into the defect.

Summary
The use of ultrasonic instruments has revolutionized the art of
endodontic retreatment. These instruments have multiple uses and have
become an integral part of the endodontic armamentarium. However, the
use of ultrasonic instruments requires specialized knowledge and development of certain skills that may require training before use.

References
[1] Martin H. Ultrasonic disinfection of the root canal. Oral Surg Oral Med Oral Pathol 1976;
42(1):929.
[2] Waplington M, Lumley PJ, Blunt L. An in vitro investigation into the cutting action
of ultrasonic radicular access preparation instruments. Endod Dent Traumatol 2000;
16(4):15861.
[3] Walmsley AD, Lumley PJ, Johnson WT, Walton RE. Breakage of ultrasonic root-end
preparation tips. J Endod 1996;22:2879.
[4] Roy RA, Ahmed M, Crum LA. Physical mechanisms governing the hydrodynamic
response of an oscillating ultrasonic le. Int Endod J 1994;27(4):197207.
[5] Kulild JC, Peters DD. Incidence and conguration of canal systems in the mesiobuccal root
of maxillary rst and second molars. J Endod 1990;16(7):3117.
[6] Weller RN, Hartwell GR. The impact of improved access and searching techniques on
detection of the mesiolingual canal in maxillary molars. J Endod 1989;15(2):823.
[7] Instructions for use. BUCTM non-surgical ultrasonic endodontic instruments. Fenton
(MO): Spartan Marketing Group. Available at: http://www.obtura.com/bucaccesstips.html.
Accessed on January 21, 2004.
[8] Buoncristiani J, Seto BG, Caputo AA. Evaluation of ultrasonic and sonic instruments for
intraradicular post removal. J Endod 1994;20:4869.
[9] Berbert A, Filho MT, Ueno AH, Bramante CM, Ishikiriama A. The inuence of
ultrasound in removing intraradicular posts. Int Endod J 1995;28:1002.
[10] Johnson WT, Leary JM, Boyer DB. Eect of ultrasonic vibration on post removal in
extracted human premolar teeth. J Endod 1996;22:4878.
[11] Yoshida T, Shunji G, Tomomi I, Shibata T, Sekine I. An experimental study of the removal
of cemented dowel-retained cast cores by ultrasonic vibration. J Endod 1997;23:23941.
[12] Bergeron BE, Murchison DF, Schindler WG, Walker WA. Eect of ultrasonic vibration
and various sealer and cement combinations on titanium post removal. J Endod 2001;27(1):
137.
[13] Ruddle CJ. Micro-endodontic nonsurgical retreatment. Dent Clin North Am 1997;41(3):
42954.
[14] Ruddle C. Microendodontics. Eliminating intracanal obstructions. Oral Health 1997;87(8):
1921, 234.
[15] Sattapan B, Nervo GJ, Palamara JE, Messer HH. Defects in rotary nickel-titanium les
after clinical use. J Endod 2000;26(3):1615.
[16] Jeng HW, ElDeeb ME. Removal of hard paste llings from the root canal by ultrasonic
instrumentation. J Endod 1987;13(6):2958.

Dent Clin N Am 48 (2004) 3554

Electronic apex locator


Euiseong Kim, DDS, MSD, PhD
Seung-Jong Lee, DDS, MS*
Department of Conservative Dentistry, School of Dentistry, Yonsei University,
134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, Korea

Locating the appropriate apical position always has been a challenge in


clinical endodontics. The cemento-dentinal junction (CDJ), where the pulp
tissue changes into the apical tissue, is the most ideal physiologic apical limit
of the working length. It also is referred to as the minor diameter or the
apical constricture. However, the CDJ and apical constricture do not always
coincide, particularly in senile teeth as a result of cementum deposition,
which alters the position of the minor diameter. Therefore, setting the apical
constricture as the apical limit of the working length, where it is easy to
clean and shape or obturate the canal, is recommended [1,2].
The apical constricture of the root also does not coincide with the
anatomic apex. It is deviated linguo-buccally or mesio-distally from the root
[35]. If the exit deviates bucco-lingually, it is very dicult to locate
accurately the position of the apical foramen using only roentgenograms,
even with multidirected angles. Frequently, a le needs to be inserted into the
canal to force it through the apical foramen, in order for the exit to be veried.
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. EALs are particularly useful when the apical portion of the canal
system is obscured by certain anatomic structures, such as impacted teeth,
tori, the zygomatic arch, excessive bone density, overlapping roots, or
shallow palatal vaults. Indeed, EALs currently are being used to determine
the working length as an important adjunct to radiography. EALs help
to reduce the treatment time and the radiation dose, which may be
higher with conventional radiographic measurements. In addition, EALs

* Corresponding author.
E-mail address: sjlee@yumc.yonsei.ac.kr (S-J. Lee).
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.10.005

36

E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

were reported to be an accurate and reproducible method as the newest thirdgeneration type and can acknowledge a root perforation. However, some
questions still exist as to whether the accuracy of EAL can be aected by the
dierent types of electrolytes [19,43,45], the types of electronic working
mechanism, and the conditions of the root canal, such as pulp vitality
[20,31,34], or foramen size [51,52]. This article reviews the history and the
working mechanism of the currently available EALs, and suggests the correct
use of an apex locator for a better canal length measurement.

History of EALs
Traditional-type apex locators (resistance or impedance type)
In 1918, Cluster [6] rst put forth the idea that the root canal length could
be determined by using the electrical conductance. Little was done with this
idea until 1942 when Suzuki [7] reported a device that measured the
electrical resistance between the periodontal ligament and the oral mucosa.
He discovered that in dogs, the electrical resistance between the root canal
instrument inserted into a root canal and an electrode applied to the oral
mucous membrane registered a consistent value of approximately 6.5 Kx.
These principles were not examined further until Sunada [8] performed
a series of experiments on patients and reported that the electrical resistance
between the mucous membrane and the periodontium was consistent,
regardless of the age of the patients or the shape and type of the teeth. In
1987, Huang [9] reported that this principle is not a biologic characteristic,
but rather a physical principle.
Inoue [10] reported a modication that incorporated the use of an
audiometric component that permitted the device to relate the canal depths
to the operator via low-frequency audible sounds. One of the most widely
used apex locators in the 1970s and 1980s, the Sono-Explorer (Union
Broach, New York, New York), was developed using this modication. By
1975, newer units such as the Neosono (Amadent, Cherry Hill, New Jersey)
and many other resistance-type apex locators became available. They have
improved circuitry, are more compact, and are easier to operate [11].
However, these resistance-type EALs often yield inaccurate results when
electrolytes, excessive moisture, vital pulp tissue, exudates, or excessive
hemorrhage are present in the canals [1214]. (The eect of the canal
contents on the accuracy of an EAL is discussed later in this article.)
A new apex locator, the impedance type, was developed in the late 1980s to
improve the resistance-type apex locators. The impedance-type EAL uses the
electronic mechanism that the highest impedance is at the apical constricture,
which is the narrowest portion of the canal where the impedance changes
drastically, when a canal is thought of as being a long hollow tube [15].
However, a question also was raised as to whether this mechanism could be
applied to the real root canal with various anatomical complications [16].

E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

37

The Endocator (Hygienic Corporation, Akron, Ohio) was an example of


an impedance-type apex locator. This device used a large le coated with
Teon, which was dicult to use in narrow canals; in addition the Teon
peeled o in curved canals. Another disadvantage with this device was that
the patient sometimes felt uncomfortable due to the high current used, and
the calibration had to be done before using the device [17].
Frequency-dependent apex locators
The newest type of EAL was introduced in the early 1990s in an eort to
obtain a more accurate canal length measurement in various canal
circumstances. It uses more advanced technology and measures the
impedance dierence between the two frequencies or the ratio of two
electrical impedances. In 1990, Yamashita [18] reported on a device that
calculated the dierence between two impedances from two dierent
frequencies, which were generated with composite sine wave current sources,
and was marketed as the Endex (Osada Electric Co., Tokyo, Japan). It
works by comparing the dierence in impedances using the relative value of
two alternating currents at frequencies of 1 and 5 kHz. As the le moves
toward the apex, the dierence becomes greater and shows the greatest value
at the apical constricture, allowing for a measurement of that location. The
major advantage of this device is that it works well regardless of the
presence of pus or electroconductive environments in the canal [19,20].
However, a disadvantage is that a calibration needs to be done each time.
In 1991, Kobayashi et al [21] reported on the ratio method for
measuring the root canal length, which was the basic working mechanism of
the Root ZX (J. Morita Corp., Tustin, California) [21]. This device measures
the impedances of 0.4 kHz and 8 kHz at the same time, calculates the quotient
of the impedances, and expresses this quotient in terms of the position of the
le inside the canal. This quotient is barely aected by the electrical
conditions inside the canal [14]. In addition, it is unnecessary to calibrate this
device each time because the microprocessor automatically controls the
calculated quotient to have a relationship with the le position and the digital
read out when the le is inserted into the coronal portion of the canal [22].
This device was reported to be quite accurate in various conditions
[2325].
The AFA (all uids allowed) Apex Finder Model 7005 (Analytic
Endodontics, Orange, California) is another type of frequency-dependent
EAL, which uses ve dierent frequencies (0.5, 1, 2, 4, 8 kHz). The Bingo
1020 (Forum Engineering Technologies, Rishon Lezion, Israel) uses two
separate frequencies, 400 Hz and 8 kHz, but only a single frequency at
a time. The use of a single-frequency signal eliminates the need for lters
that separate the dierent frequencies of the complex signal. In addition, the
position of the le tip in the Bingo 1020 is calculated based on the measurements of the root mean square value of the signal. The manufacturers

38

E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

claim that a combination of these two techniques increases the measurement


accuracy [37].

Apex locators with other functions


EALs with additional functions were developed in the late 1990s. The
Solfy ZX (J. Morita Corp.), which is a combination of an ultrasonic hand
piece and a Root ZX, was designed to prevent overinstrumentation by
stopping the ultrasonic vibration when the le reaches the required location.
The Tri Auto ZX (J. Morita Corp.) is a Root ZX with a cordless
rechargeable electric hand piece that uses a Ni-Ti rotary le with 260 to 280
revolutions per minute (rpm) [26]. When the le has reached the required
location, this device allows the le to rotate back out of the canal, thereby
preventing overinstrumentation. In addition, it also prevents the fracture of
the Ni-Ti rotary le by allowing the le to rotate back out if it goes over the
set auto-torque-reverse mechanism threshold of 40 to 80 g/cm [26]. This
unique function appears to be quite useful as the Ni-Ti rotary le becomes
more popular. However, based on our clinical experience, large sized rotary
les had a tendency to slow down the rpm speed, possibly due to the low
torque setting. In addition, it has the disadvantage that the number of rpm
reduces with increasing pressure due to the limitation of the rechargeable
battery.
Recently, the Dentport ZX (J. Morita Corp.) was introduced to the
market. The Dentaport ZX is comprised of two modulesthe Root ZX
module and the Tri Auto ZX module. Both functions can be used by
exchanging the back cover. In the Tri Auto ZX module, it appears that the
le was easily controlled when using the hand piece at 50 to 800 rpm and
a torque ranging from 30 to 500 g/cm. One advantage of the Dentport ZX is
that it has an auto apical slow-down functionwhen the rotary le reaches
the apical constricture, the rpm slows down allowing for a careful sculpture
of the apical portion. However, further research is needed to determine the
eect of a le fracture when the rpm changes inside the canal.
Devices that combine an apex locator and an electrical pulp tester also
have been marketed. One example is the Elements Diagnostic Unit (SybronEndo, Orange, California). It has a separate monitor called a Satellite,
which can be clipped to the patients napkin or other surface.

General accuracy of frequency-dependent EALs


Before the era of frequency-dependent EALs, the accuracy of traditional
EALs was inconsistent and aected by many variables [9,16,2729]. With
traditional-type EALs, the accuracy depends more on the individual
operators skill and the various canal conditions, such as the existence of
electroconductive solution. One of the alleged advantages of frequency-

E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

39

dependent EALs is that it operates accurately, even under dierent wet


canal conditions. According to recent publications [34,42,57], the accuracy
of frequency-dependent EALs is much higher than that of traditional-type
EALs (simple-resistance type or impedance type). A number of experiments
were conducted using both in in vivo and in vitro models (Table 1). Most of
the EAL measurements were compared with the actual tooth length.
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, NaOCl, water) with that of a traditional-resistance type
EAL, the RCM Mark II (Evident Dental Co., Ltd., London, United
Kingdom). The overall accuracy of the Endex (71.7%) was higher than that
of the RCM Mark II (43.5%), at a 0.5-mm clinical tolerance.
A similar study [30] compared the Apit (Osada Electric Co., Los Angeles,
California) with a traditional-type EAL (Odontometer, L. Goof Co.,
Horrsholm, Denmark) in vivo. The Apit tended to yield more reliable results
than did the Odontometer. The average deviation of the Apit was 0.14 mm
(range = 0.85 to 0.65 mm) with a 93% accuracy at a 0.5-mm clinical
tolerance, whereas the average deviation of the Odontometer was 0.36 mm
(range = 0.35 to 2.45 mm) with a 73% accuracy at a 0.5-mm clinical
tolerance. This dierence was statistically signicant (P \ 0.001).
In another in vivo experiment using vital or necrotic pulps, Mayeda [31]
reported that all measurements were within a narrow range (0.86 mm to
0.50 mm), with an 88% accuracy at a 0.5-mm clinical tolerance when
measured from the apical foramen. Shabahang et al [23] examined 26 root
canals of the vital teeth to evaluate the performance of the Root ZX. After
measuring the distance between the tip of the endodontic le and the apical
foramen, they found that the Root ZX located the apical foramen precisely
in 17 canals (65.4%), was short in 1 canal (3.8%), and was overextended in 8
canals (30.8%). However, the accuracy was 96.2% at a 0.5-mm clinical
tolerance. Vajrabhaya and Tepmongkol [24] tested the Root ZX under
clinical conditions using vital and nonvital pulp, and reported 100%
accuracy when less than 1 mm from the apical foramen and less than 0.5 mm
beyond the foramen were used as the acceptable range.
Several experiments have used radiographic lengths as a reference. Frank
and Torabinejad [32] compared the Endex with radiographic measurements.
They reported that the Endex located the apical constriction accurately
within a 0.5-mm clinical tolerance in 89.64% of 185 moist canals. Similar
results were obtained when the Endex was tested on a human cadaver [33].
The mean of the absolute values of the deviations from the apical
constriction for the apex locator (0.259 mm) was signicantly lower than
that for the radiographic method (0.578 mm). Eighty-nine percent of
the EAL was within a 0.5-mm clinical tolerance whereas 70% was in the

40

Table 1
Accuracy of frequency-dependent apex locators
Year

Study type

EAL

N (canals)

Comparison

Frank et al [32]
Mayeda [31]
Felippe and Soares [52]
Arora and Gulabivala [20]
Czerw et al [41]
Pratten and McDonald [33]
Lauper et al [30]
Shabahang et al [23]
Vajrabhaya and Tepmongkol [24]
Ounsi [59]
Dunlap et al [50]
Pagavino et al [25]
Ibarrola et al [58]
Ounsi and Naaman [49]
Lee et al [47]
Meares and Steiman [42]
Neekoofar et al [57]
Pommer et al [34]
Kielbassa et al [40]

1993
1993
1994
1995
1995
1996
1996
1996
1997
1998
1998
1998
1999
1999
2002
2002
2002
2002
2003

Patientradiograph
Patientextract
Extracted teeth
Patientextract
Extracted teeth
Cadaverextract
Patientextract
Patientextract
Patientextract
Extracted teeth
Patientextract
Patientextract
Extracted teethb
Extracted teeth
Patientextract
Extracted teeth
Extracted teethc
Patientradiograph
Patientextracte

Endex
Endex
Endex
Endex
Root ZX
Endex
Apit
Root ZX
Root ZX
Endex
Root ZX
Root ZX
Root ZX
Root ZX
Newly designed
Root ZX
Neosono Ultima EZ
AFA apex nder
Root ZX

185
33
350
61
30
27
30
26
20
34
34
29
16
36
31
40
54
152
105

Radiographic apex
Apical foramenM
Apical foramenD
Apical foramenM
Apical foramenD apical
ConstrictionM
Apical foramenM
Apical foramenM
Apical foramenM
Apical foramenD apical
ConstrictionM
Apical foramenSEM
Apical constrictionM
Major diameterD
CDJM
Apical foramenD
Apical foramenD
Radiographic apex
Minor diameterD

Abbreviations: D, direct view (magnier); M, microscope; SEM, scanning electron microscope.


a
Within 0.5 mm.
b
Preared canal.
c
Ni-Ti le was used.
d
Radiographic apex 1  0.5 mm.
e
Primary teeth.
f
Within 1 mm.

Accuracya
89.6%
87.9%
96.5%
71.7%
100%
89%
93%
96.2%
100%
84.56%
82.3%
82.75%
87.5%
84.72
92%
83%
94.4%
85.5%d
64.8%f

E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

Reference

E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

41

radiographic length. The recently marketed AFA Apex Finder [34] also
showed a high accuracy in clinical situations. When compared with
radiographic measurements, in 86% of the roots evaluated, the le tip
position (as indicated by the Apex Finder) was located within 0.5 mm of
a point 1.0 mm short of the radiographic apex.
In vitro studies
Felippe and Soares [52] tested the Apit in an isotonic saline container
model and found that 96.5% of 350 human teeth located the apical foramen
at a 0.5-mm clinical tolerance. Brunton et al [35] performed an in vitro
experiment to determine whether the use of an EAL (Analytic AFA) could
reduce radiograph exposure. In the group that did not use the EAL (25
teeth), 14 retake radiographs were required to determine the working length,
whereas in the group that used the EAL, no retake radiographs were
required. The EAL was extremely accurate in locating the apical foramen
with all the teeth tested within a 0.5-mm clinical tolerance. In contrast, only 15 (60%) teeth tested using radiographs alone were within the
0.5-mm clinical tolerance of the anatomic apex. El Ayouti et al [36] reported that the electronic working length measured by the Root ZX reduced
the percentage of overestimation to 21% compared with radiograph only.
Recently, the Bingo 1020 was introduced to dental practice. Kaufman
et al [37] compared this new frequency-dependent EAL with the Root ZX
and found that the Bingo 1020 was consistently more accurate than was the
Root ZX, although both units measured the tooth length with great
accuracy.
Digital radiography was compared with the Apit EM-S3 in a wellcontrolled in vitro model [38]. The electronic method was satisfactory in
67.8% of cases with a 0.5-mm clinical tolerance, versus 50.6% and 61.4%
for the conventional and digital radiologic methods, respectively. The
authors [38] concluded that none of the techniques were totally satisfactory
in establishing the true working length.
The 0.5-mm clinical tolerance is considered to be the strictest acceptable
range. Therefore, measurements attained within this tolerance were
considered to be highly accurate. However, some authors [39,40] prefer
the 1-mm range. Shabahang et al [23] reported that because root canals
frequently lack a well-delineated apical constriction, an error tolerance of
1 mm can be deemed clinically acceptable.
Accuracy of frequency-dependent EALs in dierent electrolytes
A major advantage of frequency-dependent EALs is that they operate
even with a high electroconducting irrigant such as sodium hypochlorite.
The operation is based on the principle of the relative dierence or a quotient
of two or more impedances generated at each dierent frequency. Although

42

E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

frequency-dependent EALs enhance the measurement accuracy, several


questions as to whether the dierent electrolytes in the canal or the size of
the root canal aect the accuracy still remain.
Many studies showed promising results with this third-generation device;
most of these studies focused on the Endex (Apit) and the Root ZX. Frank
and Torabinejad [32] compared the Endex measurements with the
radiographic measurements in 185 root canal lengths. They found that the
Endex located the apical constriction accurately within the 0.5-mm clinical
tolerance in 89.64% of moist canals. The presence of an apical radiolucency
or a restoration; the length of the canal; the type of moisture; and the pulpal
and periapical conditions, such as hemorrhage, exudate, or sodium hypochlorite, did not inuence the results. However, the measurements obtained
in the dried canals presented a variety of inconsistent and nonpredictable results. The authors [32] explained that this was due most likely to the
operators not drying the canals completely. When the dried canal was
compared with a distilled waterlled canal [41] in an in vitro salinegelatin
model, the Root ZX showed no dierence between the distilled water and
dry canal.
To determine whether the concentration of sodium hypochlorite
inuenced the accuracy of the Root ZX, Meares and Steiman [42] ushed
the canal with 2.125% and 5.25% sodium hypochlorite and the measurements from the in vitro model then were compared with the actual canal
lengths. No signicant dierences were found between the experimental
groups. The authors [42] suggested that the Root ZX was not adversely
aected by the presence of sodium hypochlorite.
In contrast, there is still a concern as to whether high electroconductive
irrigants such as blood, saline, a local anesthetic solution, irrigant uids, and
sodium hypochlorite can aect the accuracy of the EAL performance.
Several studies warned that a high electroconductive solution might aect
the accuracy. Fouad [19] compared the accuracy of the Endex with that of
the traditional-type EALs with regard to the eects of the uids in the canal
and the variation in the foramen size. The accuracy of the Endex at the
0.5-mm clinical tolerance was 73% in the smaller apical foramens and
57% in the larger foramens. When the Endex was used in the dry canals, it
showed a 90% accuracy in the smaller foramens but only a 57% accuracy
was observed in the larger apical foramens. 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.
Jenkins et al [43] evaluated the accuracy of the Root ZX in vitro in the
presence of a variety of endodontic irrigants, 2% lidocaine with 1:100,000
epinephrine, 5.25% sodium hypochlorite, RC Prep (Premier Dental
Product, Philadelphia, Pennsylvania), liquid ethylenediaminetetraacetic acid
(EDTA), 3% hydrogen peroxide, and Peridex (Zila Pharmaceuticals, Inc.,

E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

43

Phoenix, Arizona). The results showed that the Root ZX reliably measured
the canal lengths to within 0.31 mm, regardless of the irrigants. However,
the largest deviation from the actual canal length was obtained with NaOCl.
The authors [43] stated that considering the widespread utility of NaOCl as
an intracanal irrigant, the increased variance of this irrigant should be
considered.
Pilot and Pitts [44] conducted a sophisticated study on the prediction
error of the EAL (Sono Explorer Mark IV, Union Broach). They evaluated
the impedance change at dierent locations in the root canal system with
various frequencies and canal irrigants and calculated the prediction error
when the EAL was used in these various conditions in vivo. No signicant
dierence was noted in the prediction error at dierent frequencies
(P > 0.05). However, the prediction error was signicant with respect to
the dierent irrigants (RC Prep, 70% isopropyl alcohol, 14.45% EDTA
sodium solution, normal saline, and 5.25% NaOCl) (P \ 0.02). A higher
prediction error was apparent for the more conductive solutions, such as
NaOCl. These results suggest that although the working mechanism is
unclear, the dierent electroconductivities somehow aect the EAL
measurement. When the electrical resistance of the most frequently used
irrigants were measured, NaOCl was much higher (10 times), whereas H2O2
was much lower (50 times), than saline [28]. It was speculated that the
change in the electroconductivity shifts the quotient curve of the frequency
ratio.
Kim et al [45] reported that there were tendencies toward a short
measurement in a high electroconductive solution such as NaOCl, whereas
longer measurements were in the lower electroconductive solution. These
tendencies were expressed by a voltage dierence. To minimize the measurement errors, they developed a new circuit that could automatically
compensate for the voltage dierences in the dierent irrigating solutions.
As a result of this compensation, the errors were signicantly reduced, on
average from 0.54 mm to 0.18 mm in the H2O2 solution and from 0.33 mm
to 0.01 mm in the NaOCl solution in an in vitro study. The accuracies
based on a 0.5-mm clinical tolerance were improved for the H2O2 and
NaOCl solutions from 71.1% to 91.1% and from 82.2% to 100%,
respectively. Briey, the impedance ratios and voltage dierences were
obtained from the three dierent irrigating solutions (saline, NaOCl, and
H2O2) in an extracted tooth model, using the conventional impedance ratio
method with two sinusoidal waves (0.5 and 10 kHz). From a total of 45 root
canals examined in each solution, the distributions of the voltage dierences
and the measurement errors were obtained. The voltage dierences
measured were generally larger in H2O2 and smaller in NaOCl when
compared with saline. The measured lengths were generally longer in H2O2
and shorter in NaOCl compared with saline. The impedance ratio of the two
dierent frequencies represented the position of the le, whereas the voltage
dierence represented the status of the uid in the root canal. Each irrigant

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E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

Fig. 1. Distributions of voltage dierence versus error for the three solutions in the canal. LL
and UL are decision boundaries that classify a smaller voltage dierence solution (NaOCl)
and a larger voltage dierence solution (H2O2) for 45 extracted root canals (in vitro).

was classied statistically using a Bayes linear classier (Fig. 1). The
compensating value was determined in proportion to the dierence between
the measured voltage dierence and either the upper limit (UL) or lower
limit (LL), which then was added or subtracted to the impedance ratio for
compensation. Therefore, during the actual determination of the working
length, the le would go deeper in a higher electroconductive condition such
as NaOCl, whereas it would go less deep in a lower electroconductive
condition such as H2O2.
When this compensation circuit was tested in clinical situations, Nam
et al [46] reported that the mean error was 0.14  0.27 mm from the
constriction point, and 95.2% of the measurements were within the clinical
tolerance of 0.5 mm. Lee et al [47] also reported promising results from the
compensation circuit. When the distances from the major foramen and CDJ
were measured, the average distance of the measurements was 0.13 mm
from the major foramen with a range of 0.28 to 0.46 mm. The average
distance from the detectable 26 CDJ samples was 0.18 mm with a range of
0.98 to 0.65 mm. The measurement accuracies were 94% (29/31) from the
major foramen and 92% (24/26) from the CDJ with a 0.5 mm tolerance.
There were no dierences between either the smaller (\#25) and larger
apical foramens (#25), or the vital and nonvital pulps, respectively.
Measurements can change as a result of dierent measuring methods
such as what point of the unit the operator uses as a reference and whether
to use the major diameter or the constriction point from the EAL reading.
The operation manual of the Root ZX [48] recommends that the le be

E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

45

inserted until the meter reads 0.5 mm. The le then is advanced with a slow
clockwise turn until the word APEX begins to ash. When the apex is
reached, the le is turned slowly counterclockwise until the meter reads 0.5
mm, and the measurement is then read. The manual also advises that 0.5 to
1 mm be subtracted from the EAL measurements, as indicated by the 0.5
mark on the meter, to place the lling material above the apical seat.
However, several authors have questioned using the 0.5 mark. Some
recommend that the APEX mark be used instead of the 0.5 or 1.0 mark
[25,49].
Ounsi and Naaman [49] performed an in vitro experiment to evaluate the
performance of the Root ZX at two dierent settings: the 0.5 and APEX
marks. The results showed that if the 0.5 mark was selected, the mean value
of the dierence between the EAL and actual length was outside of the
0.5-mm clinical tolerance (50%). However, when the APEX mark was
selected, the mean value was within this tolerance range (84.72%).
Therefore, they discouraged the use of the 0.5 mark as advised by the
manufacturer, and suggested that the canal length be measured when the
APEX mark is reached [49].
Another study [25] evaluated the accuracy of the Root ZX in two
foramen locations: with the foramen at the end of the root tip and with the
foramen deviated from the main axis. The clinical accuracy was 82.75%
with a tolerance level of 0.5 mm when the measurements were read at the
APEX mark. In 28 out of 29 examined teeth, the le tip protruded beyond
the apical foramen with a range between 0.12 mm and 0.85 mm. The authors
of this study [25] recommended the withdrawal of the instrument by
approximately 0.5 to 1 mm to avoid overpreparation.
Similar results were reported for the Endex. Arora and Gulabivala [20]
compared the accuracy of the Endex in the presence of vital and nonvital
pulp tissue and commonly encountered canal electrolytes (pus, NaOCl,
water) with that of a traditional-type EAL, the RCM Mark II. In general,
longer readings occurred with the Endex (80.3%) than with the RCM Mark
II (50.8%). The authors [20] suggested that the manufacturers calibration
of the Endex resulted in an overinstrumentation of the canal length. Mayeda
[31] found that the Endex consistently located a point that was closer to the
major diameter than the apical constriction. Because one third of the
measurements were long, and another one third were right at the apical
foramen, most of the measurements would actually be beyond the apical
constriction. The results indicated that the accuracy of all measurements
were within a narrow range (0.86 mm to 0.50 mm), with 88% at the
0.5-mm clinical tolerance from the major apical foramen. However, if
the readings from the apical constriction instead of the major foramen were
counted, the accuracy would fall to 70% for vital tissue and 69% for
necrotic tissue.
In an in vivo study with a newly designed compensation circuit, Lee et al
[47] reported that most measurements (19/25) were beyond the CDJ. The

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E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

reason for this was attributed to the fact that the machine reads the largest
gradient of the impedance ratio at the point where the periodontal ligaments
meet. However, the question as to how the measurements could be
reproduced consistently is more important than where to read the
measurements. No matter where the machine points, if the machine
pointing is consistent and the position and the average distance between the
le tip and the true CDJ are known, then an accurate length can be obtained
by subtracting the average distance directly from the machine reading. In
this study [47], the authors used the SDs to evaluate the measurement
consistency. Eighty-one percent of the major foramen and 65% of the CDJ
measurements were within 1 SD, and 97% of the major foramen and 92% of
the CDJ measurements were within 2 SDs. Again, these results showed that
the measurements from the major foramen were more consistent than were
those from the CDJ. The authors [47] suggested that SDs be used to test the
accuracy along with the average discrepancy with the 0.5-mm clinical
tolerance.
Eect of pulpal vitality on the accuracy of EAL
Most studies [24,31,47] have reported that pulpal vitality does not aect
EAL accuracy. Mayeda et al [31] conducted a study to determine whether
the pulp status (ie, vital or necrotic) makes a dierence in the determination.
In this in vivo study, 33 teeth, both vital and necrotic, were measured using
the Endex apex locator and then were radiographed. The results indicated
that all the measurements were within a narrow range (0.86 mm to 0.50
mm). There was no statistical dierence in the measurements between the
vital and necrotic canals (vital group, mean 0.057, SD 0.32 mm,
range 0.71 to 0.5; nonvital group, mean 0.11, SD 0.35 mm,
range 0.86 to 0.43). Similar results were supported by succeeding
investigations with the Root ZX [24] and the newly designed circuit [47].
There have been several disagreements on the eect of pulpal vitality on
the accuracy of EAL. When the inuence of root canal status on the
determination of root canal length using the AFA Apex Finder in vital and
necrotic canals was compared, the results showed a higher accuracy for
determining the apical constriction in vital canals (93.9%) than in necrotic
canals (76.6%), and this dierence was statistically signicant (P  0.05)
[34]. The authors [34] suggested that in necrotic cases with inammatory
root resorption, the apical constriction might be altered or even nonexistent
with no viable periodontal tissue to respond to the EAL, which would cause
a lower accuracy. Arora and Gulabivala [20] reported that the Endex
provided a better reading in vital tissues (88.9%), whereas the readings for
necrotic pulp were substantially lower (45.4%) within a 0.5-mm clinical
tolerance. In a study using the Root ZX, Dunlap et al [50] compared the
canal length in vital and necrotic canals. The mean distance from the
constriction was 0.21 mm in the vital canals and 0.51 mm in the nonvital

E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

47

canals; 52.9% of the vital versus 23.5% of the nonvital readings of the
coronal or right at the apical constriction were measured. However, no
statistical dierence was found. Two necrotic pulps with a periapical
radiolucency measured greater than 1.5-mm error beyond the constriction.
It was conceived that these periapical radiolucencies lacked a periodontal
ligament and the periapical bone may have caused the abnormally long
reading. The authors also speculated that apical resorption by the longstanding periapical radiolucency may have resulted in the destruction of the
apical constriction.

Eect of foramen size on the accuracy of EAL


In general, there is a consensus that the le size does not aect the
accuracy of EALs. Nguyen et al [51] conducted an in vitro experiment to
observe the eect on the measurement of the relative diameters of the le
and the root canal using the Root ZX. The length of the enlarged canals was
measured using small-sized les and large les matching the canal diameter.
The initial canal length (IL) was measured using the EAL by negotiating
a size 10 le to the apical constriction. The canal was enlarged to size 60 with
the rotary les, and the nal length (FL) measurements then were obtained
using a size 10 le and a size 60 le. The position of the le tip was observed
histomorphometrically after the apical 4 mm of the canal was exposed
by grinding the buccal aspect of the root. Dierences between the FL-10,
FL-60, and IL were similar.
In an in vitro experiment [52], the Apit also was used to evaluate the
possible inuence of the size of the instrument on the measurements.
The actual lengths, which were taken with a #15 le, were compared with
the EAL lengths obtained using the size comparable to the diameter of the
root canal. In all the teeth measured, the results with the larger les were the
same as or less than 0.5 mm dierent from the results obtained with the #15
les. When the initial le sizes were grouped according to the le size #25,
Lee et al [47] reported that there were no dierences between the smaller
(\#25) and larger apical foramens (#25).

Eect 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. 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. The measurements were
accurate in 62.7% of cases with a 0.5-mm clinical tolerance when compared
with direct visual measurements. The authors [39] also reported that there
were dierences between the operators measurement abilities, suggesting

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E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

that the accuracy of the EAL in apical resorption may depend more on the
operators experience. However, Shabahang et al [23] reported that the Root
ZX could locate the root end consistently, even with the resorption lacunae.

Accuracy in primary teeth


The location of the actual apical foramen in the primary teeth, which are
in the process of physiologic resorption, provides a great challenge to
clinicians. However, conventional methods are not always applicable
because the apical aperture is exposed to continuous and sometimes
irregular resorption. In these instances, it is even more imperative to
minimize the periapical damage to protect the succedaneous tooth bud.
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 dierent degree of root resorption. They reported that the
Root ZX had an accuracy that was similar to the actual length and the
radiograph lm. They also stated that the use of the Root ZX was quick,
comfortable, and accurate, and was preferred over the radiographic method.
Kielbassa et al [40] conducted a similar study using the Root ZX, but in
vivo. They reported that the device had a sucient accuracy, with a tendency
to slightly underestimate the root canal length just short (average 0.98
mm) of the apex. The tooth, the root canal type, the status of the periapex,
and the clinical conditions did not inuence these results.

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, particularly when it occurs
bucco-lingually [55]. Kaufman et al [56] compared the abilities of the Root
ZX, Apit III (Endex), and Sono Explorer Mark II in detecting a root
perforation. When tested on 30 extracted human teeth in vitro, all the tested
EALs were clinically acceptable, where the tip of the le ended 0.06 mm to
0.60 mm short of the external outline of the root surface. Therefore, the use
of an EAL for making an early detection of a root perforation appears to be
very eective.

Eects of dierent metal types


The question as to whether dierent types of metal can aect the
accuracy of EALs has been raised, but this does not appear to be a problem.
Nekoofar et al [57] evaluated the accuracy of the Neosono Ultima EZ
(Amadenat) using two dierent types of metal: nickel-titanium and stainless

E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

49

steel. The accuracy of the nickel-titanium and stainless steel was 94% and
91%, respectively, and there was no statistically signicant dierence.

Clinical suggestions
Conventional radiograph still is needed
Recent publications regarding frequency-dependent EALs appear to
agree that EALs are more reliable than is conventional radiography.
Whether to trust EALs or radiography depends on how familiar the
operator is with each method. We tend to trust EALs more when there is
a stable electronic sign with reasonably controlled exudates and without any
metallic restorations. However, when the sign is unstableparticularly with
metallic restorations, severely undermined caries, severe exudation, or
a wide-open apexa comparison of the EAL reading with the radiograph is
strongly recommended. Besides, EALs only provide the electronic impedance and not the canal shape. To obtain anatomic information of the roots
and canals, a radiograph still is mandatory in an endodontic procedure.
Working length is changing continuously
The working length changes constantly throughout the root canal
treatment. During the canal preparation procedure, the le inadvertently
may go beyond the apical foramen, breaking the apical constriction and
creating an oval-shaped exit, which leaves a thin wall at the coronal part of
the dentin. As the le tip touches the most coronal margin of the oval exit,
the unit will show an apex sign, thereby measuring a shorter length (Fig. 2B)
than the initial working length (Fig. 2A). This may occur more frequently
because the use of a rotary instrument is increasing in the endodontic
practice. A straightening of the curved canal can be another cause. We
measured the changes in the working lengths between before and after canal
shaping from 5000 root canals using frequency-dependent EAL and showed
that there were some changes in the working lengths (Table 2). EALs were
useful in conrming the working length not only during the endodontic
procedure but also in the nal working immediately before the obturation.
When EALs are used to verify the nal working length, the following things
should be considered. First, the apical area may become too enlarged
leaving an extremely or stripped thin dentin wall. Care needs to be taken so
as not to break the apical seat or the remaining thin dentin wall. A le size
that ts snuggly inside the apical canal is recommended. When the nal
EAL is used in a dried canal situation, the le position may become directly
in contact with the apical soft tissue, where the meter sign of the EAL drops
sharply to the APEX mark. In this case, it is advised to subtract 0.5 to 1 mm,
depending on the size of the apical foramen (usually, a larger subtraction for
a larger-sized foramen).

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E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

Fig. 2. As the le tip touches the most coronal margin of the oval exit, the unit shows the apex
sign. (A) Initial sign of apex. (B) Sign of apex after canal preparation.

Common Problem Solving


The following are problems frequently encountered by general practitioners when using EALs.
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 le
touches the metallic restorations or when there is a cervical leak through the
subgingival caries. Removing the metallic restoration or simply blowing air
onto the wet chamber usually solves this problem.

Table 2
Dierence of the working lengths between before and after canal shaping
Root
Upper
Upper
Upper
Upper
Upper
Upper
Upper
Lower
Lower
Lower
Lower
Lower

Dierence (mm)
central incisor
lateral incisor
canine
premolar buccal root
premolar palatal root
molar mesio-buccal root
molar palatal root
central incisor
lateral incisor
canine
rst premolar
rst molar mesio-buccal root

0.3
0.4
0.4
0.3
0.5
0.4
0.4
0.2
0.1
0
0.4
0.4

E. Kim, S-J. Lee / Dent Clin N Am 48 (2004) 3554

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 orice to the apical foramen.
Sometimes, the signal remains remote from the APEX mark and then drops
abruptly as it reaches the apical foramen, which makes it very dicult to
locate the apical foramen precisely. This mostly occurs with a very dry
canal. When the le tip is at the extremely dried point, there is little or no
electric contact, even at higher frequencies. As soon as it meets with the
apical tissue, a sudden circuit breaks out, which brings the signal to the
APEX mark. When this occurs, gentle irrigation of the canal will reiterate
the normal operation of the unit. When an EAL is used in dry conditions,
such as for the nal working-length verication immediately before the
obturation, the operator must judge carefully the appropriate position from
the sharp dropping.
Apex sign from the beginning; severely bleeding or exudating canal
At times, the signal reaches the APEX mark far before the le enters the
supposed foramen area. The cause of this phenomenon is too much
electrolyte in the canal. This phenomenon occurs most often with extreme
bleeding and actively draining pus or exudates from the canal. When this
happens, the canal should be irrigated gently with sodium hypochlorite or
saline until the drainage becomes reasonably controlled. The canal may
need to be blot dried in some cases.
Premature reading, open apex
When there is an open or blunderbuss-type foramen, the meter tends to
read short from the true apical foramen. A premature reading is probably
due to the sharp drop in the gradient of the impedance ratio at the thin
dentin wall. As described previously, the machine reads the largest gradient
change in the impedance ratio wherever the le tip meets. The total
impedance is the sum of the impedance created apically and of the dentin
wall. Because the dentin wall has a much lower electrical capacitance than
does the apical foramen, the impedance change depends mainly on the
distance between the le tip and the apical foramen. When the dentin wall
becomes extremely thin, the impedance of the root dentin wall aects the
total impedance between the le tip and the lip clip, which renders
a premature reading.

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[57] Nekoofar MH, Sadeghi K, Akha ES, Namazikhah MS. The accuracy of the Neosono
Ultima EZ apex locator using les of dierent alloys: an in vitro study. J Calif Dent Assoc
2002;30(9):6814.
[58] Ibarrola JL, Chapman BL, Howard JH, Knowles KI, Ludlow MO. Eect of prearing on
Root ZX apex locators. J Endod 1999;25(9):6256.
[59] Ounsi HF, Haddad G. In vitro evaluation of the reliability of the Endex Apex Locator.
J Endod 1998;24(2):1201.

Dent Clin N Am 48 (2004) 5567

Nickeltitanium: options and challenges


Michael A. Baumann, DDS, PhD,
Univ.-Prof. Dr. med. dent.
Department of Operative Dentistry and Periodontology, Dental School,
University of Cologne, Kerpener Strae 32, D-50931 Koln, Germany

Nickeltitanium (NiTi) was developed 40 years ago by Buehler et al [13]


in the Naval Ordnance Laboratory (NOL) in Silver Springs, Maryland. The
symbols of the metals were combined with the place of invention, creating
the acronym NiTiNOL, which is used worldwide for this special type of
alloy. Using about 55 wt% Ni and 45 wt% Ti and substituting some Ni with
less than 2 wt% Co, nearly the same number of Ni and Ti atoms are
combined, being reected in the term equiatomic. This alloy is the favorite
for use in endodontics (Tables 1, 2) and is commonly referred to as 55
NiTiNOL. Another type is called 60 NiTiNOL and contains about 5% more
nickel (see Tables 1, 2). This alloy has been used for some hand les but
because of dierent properties (ie, lower shape memory eect and
increased heat treatability, together with increasing hardness) it seems to be
less useful than the 55 NiTiNOL [4].
NiTi alloys overall are softer than stainless steel, are not heat treatable,
have a low modulus of elasticity (about one fourth to one fth that of
stainless steel) but a greater strength, are tougher and more resilient, and
show shape memory and superelasticity [46]. 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. 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), which follows the naming of the
reactions of stainless steel.
This lattice organization can be altered either by temperature or stress.
Although temperature changes are used during the manufacturing process,
root canal treatment causes stress to NiTi les and a stress-induced
martensitic transformation takes place from the austenitic to the martensitic

E-mail address: Michael.Baumann@medizin.uni-koeln.de


0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.11.001

56

M.A. Baumann / Dent Clin N Am 48 (2004) 5567

Table 1
Composition of nickeltitanium rotary and hand les following an EDAX-analysisa
Composition
File type
Machined
ProFile (Dentsply Maillefer)
Hero 642 (MicroMega)
FlexMaster (VDW-Antaeos)
Hand
NitiFlex K-File (Dentsply Maillefer)
UltraFlex K-File (Texceed)
Onyx-R-File (Union Broach)

Ni

Ti

Al

Fe

Co

54,26
54,37
55,28

45,42
45,32
44,42

0
0
0

0.04
0.05
0.03

0.28
0.26
0.27

54,36
59,14
43,65

45,31
40,40
38,97

0
0
16,74

0.05
0.18
0.33

0.25
0.28
0.24

a
EDAX; Energy Dispersive Analysis of X-rays.
Data from Schafer E. Wurzelkanalinstrumente fur den manuellen Einsatz: Schneidleistung
und Formgebung gekrummter Wurzelkanal abschnitte. Berlin: Quintessenz; 1998.

phase within the speed of sound. A change in shape occurs, together with
volume and density changes. This ability of resisting stress without permanent deformationgoing back to the initial lattice formis called superelasticity. This quality is not unique to NiTi because CuZn, CuAl, AuCd,
and NiNb alloys also show it, but these alloys are less biocompatible [2,4].
The superelasticity is most pronounced at the beginning, when a rst
deformation of as much as 8% strain can be totally overcome. After 100
deformations, the tolerance is about 6% and after 100,000 deformations, it
is about 4% [6,7].
Within this range, the so-called memory eect can be observed: the
NiTi le comes back to its original straight form without showing any sign
Table 2
Properties of nickeltitanium and stainless steel
Property

55 NiTiNOL

60 NiTiNOL
cooled from 950 C

6.45
6.71
Density (g/cm3)
Melting temperature ( C)
1310
1125
Hardness
Vickers
303362
303
Rockwell
(30 above (17 below (30 water(60 furnace
TTR)
TTR)
quenched)
cooled)
Tensile strength (MN/m2) 8271172 103862 945
1062
34138 Near tensile
Yield strength (MN/m2) 621793
strength
Modulus of elasticity
83110
2169
114
114
(103 MN/m2)
Elongation %
115
60
7

Abbreviation: TTR, transformation temperature range.


, No information available.
Data from Refs. [47].

Stainless
steel
7.9
15001550
600610

2000
1600
285103 N/mm2
2

M.A. Baumann / Dent Clin N Am 48 (2004) 5567

57

of lasting deformation. Nevertheless, without any prior notice, a fracture


can occur suddenly.
The Vickers hardness number of NiTi is about 300 to 350, far beneath
that of stainless steel, which is about 530. Both values are far higher than
dentin, however, which has a Vickers hardness number of up to 70 [8], and
root canal dentin, which has a value of nearly 30 to 35 [9]. Nevertheless, the
surface of NiTi instruments obviously is not homogenous, and Serene et al
[10] found that the cutting edges were softer than the core of the
instruments. This nding meant a lower cutting eciency and a higher
wear than for stainless steel les and, therefore, a higher frequency of
exchange of les. The cutting eciency of NiTi instruments is not judged
uniformly but in the end, it is about one half or two thirds that of stainless
steel [11]. Thus, a disadvantage for NiTi hand les is the permanent rotating
manner in which modern NiTi les are used in combination with the greater
taper: although this increases the cutting ability, the wear increases, which
leads some clinicians to maintain that NiTi les are disposable instruments.
Manufacturing
In this context, the manufacturing of NiTiNOL alloys plays a key role for
understanding some inherent challenges (for details, see reference [4]).
Machining of the original NiTi wire should be conducted at 220 ft/min1
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]. Twisting, as it is done with stainless steel K les
and K reamers, is impossible due to the superelastic properties and the
memory eect. Therefore, machining and grinding is the only way for NiTi.
In the very beginning, milling marks with severe surface alterations, rollover
of the edges, and inhomogeneities often could be observed, thus leading to

Fig. 1. The surface of the early NiTi les was rough with grooves and roll overs. Quantec (1997)
is shown in the upper left panel. ProFile (1997) is shown in the upper right panel. An
experimental le (1998) is shown in the lower left panel. Modern surfaces (RaCe) are much
smoother, as shown in the lower right panel.

58

M.A. Baumann / Dent Clin N Am 48 (2004) 5567

accelerated wear, fatigue, and nally breakage (Fig. 1). Some manufacturers
have overcome this problem (Fig. 2). In addition to inhomogeneities and
surface alterations, corrosion and resistance to repeated sterilization are
issues that must be discussed.
Corrosion and sterilization
The environment of the mouth (body temperature, saliva with its salts
and electrolytes, blood) causes corrosion of NiTi alloys [12,13]. Corrosion
pits in products rich in titanium were described by some authors [1416],
whereas Edie et al [17] saw no dierence in surface characteristics under the
scanning electron microscope or in terms of oxygen contact, meaning
corrosion. United States Navy tests found that NiTi had good corrosion
resistance, good stress corrosion, and performed well in a marine
environment [2].
Dierences in the eects of sterilization on NiTi alloys also have been
fond. Older studies tested orthodontic NiTi wires. One study used dry heat,
formaldehyde vapor, and a steam autoclave. The elastic properties,
resilience, deection rate, and surface were unaltered [18]. Another group
also saw no clinical dierences [19], whereas other researchers observed
a higher stiness, reduced pseudoelasticity, and changes in load and unload
[20].
More recent studies on endodontic instruments indicate that there are
changes but that they are not seen as clinically relevant [12,21,22]. Dry heat
and steam autoclave decreased the exibility of stainless steel and NiTi les,
but the values satised International Standards Organization specications
[12]. These results were conrmed in another study with dierent les in
which sterilization altered the bending moment only slightly [22]. Clinical
use with sodium hypochlorite (NaOCl) and repeated sterilization did not
lead to a decrease in the number of rotations to breakage of the les [21].

Fig. 2. The tips of most les are more or less rounded. LightSpeed is shown in the upper left
panel; GT in the upper right; RaCe in the lower left; and Hero in the lower right., see also Fig. 5.

M.A. Baumann / Dent Clin N Am 48 (2004) 5567

59

Another study used spectroscopy to examine the chemical composition of


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

60

M.A. Baumann / Dent Clin N Am 48 (2004) 5567

Table 3
Chronology and selected data of rotary Nickeltitanium les
Instrument

Year

Cross-section

Taper

Tip

NT Engine
LightSpeed
Mity roto
ProFile
Orice Shaper
PowerR
Quantec
GT rotary
Hero 642
RaCE
FlexMaster
ProTaper
K3
Endostar
NiTi-Tee
K2
MFile

1991
1992
1993
1993
1993
1994
1996
1998
1999
1999
2000
2001
2001
2001
2002
2002
2003

Modied
U le
U le
U le
U le
U le
Modied
U le
Modied
Modied
Modied
Modied
Modied
Modied
Modied
Modied
Modied

02
00
02
0206
0508
0206
0212
04/0612
0206
0210
0206
Multiple/reverse
0210
0210
0212
0208
0206

Pilot
Pilot
Pilot
Pilot
Pilot
Pilot
Various
Pilot
Modied active
Pilot
Modied active
Modied active
Pilot
Pilot
Pilot
Pilot
Pilot

H le

K le
H le
K le
K le
K le
K le
K le
S le
Uni le
K le

of types and brands. The combination of the old idea of 360 rotation with
the new technology met with great success, and progress continues to be
made, even after 15 years.
The sequence of NiTi les opened with NT engine les by McSpadden
and the LightSpeed system by Wildey and Senia [29] and nds its
preliminary end today with the MFile by Brasseler (Table 3). Various NiTi
systems are described throughout this issue and many studies have been
designed to evaluate the advantages and disadvantages of them. A large
number of articles can be found when looking on the Internet for NiTi (424)
or NiTi and dentistry (221). A complete book on root canal treatment with
Ni-Ti instruments has been edited by Quintessence in Germany in 2002 [30]
and many scientists and practitioners around the globe focus on this new
mechanical approach to shape the root canal.
Over the years, three brands have dominated the discussion, the ideas,
and the market: LightSpeed, ProFile, and Quantec, which all share features
that are common and widespread in nearly all systems. During the last
several years, however, there have been some changes in the fundamental
design. A second generation of NiTi instruments, research, and theory has
enabled fast development and improvements that are reviewed here.
International standards organization recommendations
For almost a hundred years, instruments for manual preparation of the
root canal system have been manufactured in a similar way: there are three
main types, namely the reamer, the K le, and the H le. The common
feature of all three is that they have a total cutting length of 16 mm and an

M.A. Baumann / Dent Clin N Am 48 (2004) 5567

61

increase in diameter by 0.02 mm per millimeter. This increase in diameter is


termed a taper of 2%. For example, an instrument designated as size 25 is
25/100 mm thick at the tip (ie, 0.25 mm). At the end of the cutting edge, it is
16  0.02 mm = 0.32 mm thicker (ie, 0.25 mm + 0.32 mm = 0.57 mm).
In addition, 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. The cutting edges meet the canal wall at dierent angles
(reamer with an angle of approximately 20 , K les with 40 , and H-les
with 60 ). In addition, reamers have only around half as many cutting edges
as K les, making a reaming motion possible with only a slight tendency for
the reamer to screw itself into the canal. K les are considerably more
eective than K reamers, although because of the signicantly higher risk of
screwing themselves into the canal, they must not be turned in the canal
more than half a circle (180 ). This technique was the standard until the
NiTi era began.
Common features of nickeltitanium les
Tip
The tip is mostly rounded to serve as a guide within the canal without
cutting at all (Fig. 2; eg, LightSpeed, Quantec LX, System GT). Exceptions
are the early Quantec design, which had a sharp cutting tip with 60 or 90
(Fig. 3), the early ProFile, with some sharp edges at the end (Fig. 4, see also
Fig. 1), and FlexMaster (Fig. 5) in which the cutting edges go far to the tip.
Cutting egdes
In the beginning, cutting edges had been attened, named radial land
(ie, for LightSpeed, ProFile, Orice Shapers, GT rotary, System GT). This
attening was necessary because every permanent rotating system has the
tendency to screw into the canal. To overcome this problem, clinicians could
atten, modify, or shorten the cutting edges and vary the ute height or
taper. All of these ideas have been used in one or another systems:
Flattening the edges (radial lands): used in LightSpeed, ProFile, System
GT (see Fig. 4).
Modiying the edges: Quantec (see Fig. 3) and K3 have very complex
cutting edges that stay between the attened and sharp edges and are
thought to enhance the cutting ability and combine a big chip space
with a strong core.
Shortening the cutting edges: System GT with d0 = 0.20 mm (6.66 mm
in GT 0.12, 8 mm in GT 0.10, 10 mm in GT 0.08, and 13.33 mm in GT
0.06), RaCe les with 9 or 10 mm, MFile with 4 to 6.5 mm, and the
ultimate reduction of LightSpeed with 0.5 to 1.75 mm (Fig. 6).
Varying the ute height: examples are GT rotary les and System GT (see
Figs. 4, 6) or the MFile (see Fig. 6). RaCe nally shows alternating of
short twisted with straight areas (see Figs. 5, 6) [31].

62

M.A. Baumann / Dent Clin N Am 48 (2004) 5567

Fig. 3. The Quantec tip has gone through a special development: from a 60 degree tip (upper
left) and a 90 degree variation (upper right) to a shield tip (lower left) and a torpedo tip (lower
right).

Varying the taper: one of the very new ideas of NiTi le development is
the increase of the standardized taper, which was 2% normally
referring to the International Standards Organization standard (see
Table 3). The rst systems stayed in this tradition (NT Engine, Mity
roto) or created a no-taper variance (LightSpeed), producing parallel
walls for the rst time. Starting with ProFile, the double, triple, and
higher (greater) taper pioneered its way. A double taper or taper
0.04 means that with every millimeter of cutting length, the instrument
gets bigger by 0.04 mm. A triple taper or taper .06 means that with
every millimeter of cutting length, the instrument gets bigger by
0.06mm, and so on. There are not only even taper but some systems
like Quantec, Orice Shapers, and ProTaper also have odd taper.
The ProTaper system (see Fig. 5) dees imagination, having reverse
and multiple taper within one le [32,33].

Fig. 4. Many NiTi le brands show attened cutting edges like LightSpeed (upper left), Quantec
SC with a complex cutting surface (upper right), MFile (notice the change of ute heights;
center), ProFile (lower left), and GT rotary (change of ute heights; lower right).

M.A. Baumann / Dent Clin N Am 48 (2004) 5567

63

Fig. 5. Recently, a change to sharp cutting edges has been undertaken and some brands show
this variability. FlexMaster is shown in the upper left panel; Hero in the upper right; ProTaper
in the lower left, and RaCe in the lower right. ProTaper shows a variation of taper and a change
from ute height. RaCe exhibits an alternation of twisted and straight areas.

New approaches and challenges


When referring to reverse and multiple taper, some aspects of
contemporary le designs have been addressed. By having better ways of
manufacturing and grinding NiTi wires and calculating mathematic models
of stress [34], some manufacturers began to produce sharp cutting edges (eg,
Flexmaster, ProTaper, Hero 642). This sharp cutting edge results from
a triangular cross-section (eg, FlexMaster, ProTaper) [32,35].
To replace the old-fashioned but eective GG-burs, many manufacturers
designed similar NiTi instruments. The Orice Shapers from Dentsply
Maillefer are six instruments with high taper (5%8%) and a short working
end. File 1 from Quantec, used for crown down, is a size 25 0.06, being only 19
mm from tip to handle and exactly the same as le 8, used up to total length
with size 25 0.06, but being 25 mm length. The IntroFile from VDW-Antaeos

Fig. 6. A shortening of cutting edges is one way to decrease the tendency of NiTi les to screw
into the root dentin. GT rotary les are shown in the upper left panel; MFile in the upper right;
LightSpeed in the lower left, and RaCe in the lower right.

64

M.A. Baumann / Dent Clin N Am 48 (2004) 5567

(MunchenD) has taper 11% and a tip diameter size 22. The GT rotary les
and System GT also can serve as crown down instruments. The obvious
advantage of all these approaches is that the tip diameters are mostly smaller
than the smallest GG-bur, with size 50 thus needing a comfortable size of the
canal entrance, which cannot be expected anyway. The higher exibility of
NiTi is another point. Another way to overcome this problem has been
developed by FKG, the manufacturer of RaCe les. FKG oers stainless steel
les for crown down (0.08 taper/size 35 and 0.10 taper/size 40).
This discussion reects some of the aspects that have arisen with the
variation of NiTi le designs. A highly interesting monograph dealing with
this subject in extenso is the book Endodontic Instrumentation: Essentials for
Expertise by McSpadden [36], which will be published soon.
This discussion has been closely related to the invention of specic
endodontic motors with torque control. Fatigue, however, is an unsolved
problem and another challenge for NiTi manufacturers. The SET
identitya special box that calculates the cycles and life span of NiTi
lesmay provide an answer (see Fig. 5).
A last aspect under discussion is the enhancement of the surface hardness
of NiTi les. As previously discussed, the NiTi alloy is a strange alloy that
barely can be machined, resulting in a poor surface texture with roll overs
and grooves. Therefore, the possibilities of coating the surface is discussed in
the literature [25,3741].
One approach is ionic implant and thermal nitridation [42]. Lee et al [37]
found that the implantation of 4.8  1017 per ion/cm2 of boron increased
the surface hardness. Another approach is the thermal nitridation for 480
minutes at 500 C or ionic implantation with 150 keV nitrogen ions at doses
of 1.0  1017 per ion/cm2. The wear resistance of ProFiles was enhanced
with both approaches. Regular ProFiles showed a decrease in cutting ability
after 80 seconds, whereas the ionic implantation and thermal nitridation
showed no loss in cutting ability over 240 seconds. Finally, a physical vapor
deposition of TiN also increased the cutting ability [43] and helped the les
to withstand repeated sterilization or exposure to NaOCl [25].
Summary
A large number of studies have dealt with various aspects of NiTi les, such
as the physical and chemical characteristics of NiTi alloys and the original les
available, the biologic acceptance and allergies, the enhancement of cutting
ability and le design using plastic block studies, clinical trials, the question of
torque and fatigue, special motors, scanning electron microscope studies for
testing the cleaning and shaping ability, student studies, and many others (for
review, see reference [30]). There are some leading scientists and companies
that are driving the development of NiTi technology. Side developments of
endodontics such as dierent irrigations and lubricants, new lling methods,
apex locators in combination with high-tech endodontic motors, and others

M.A. Baumann / Dent Clin N Am 48 (2004) 5567

65

have caught the wave of technisation. In this way, endodontics is a mirror


of the world: some dentists and scientists defend their old bastions and argue
to stay with hand instrumentation, claiming the ever heard warnings that
there is nothing better than the good old times and a highly advanced
ling technique by hand; others have thrown away all their old instruments and former ways of proceeding, and are riding the wave.
Of course, permanent rotating instruments only can create round holes,
and canals are not really round all over.
Of course, circumferential ling is not possible or only restrictedly
possible with NiTi les.
Of course, there is evidence that NiTi les 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.
Of course, a complete instrumentation and herewith cleaning of canal
walls cannot be achieved by mechanical means; neither with stainless steel
hand les, NiTi hand les, or any NiTi rotary system.
Of course, every success with dental performances mainly depends on the
dentist and secondly comes from the material.
In this context, the large studies in Glasgow on plastic blocks by Dummer
and colleagues [4] and in Gottingen on extracted teeth (see review in [30]),
looking for straightening, working time, blockages, loss of working length,
fractures, and perforations found that there are dierences between brands
and that some do not proceed as well as others but overall, independent
from the study design or observer, the results for the most systems diered
only slightly and were highly constant [30].
Some universities in Germany (ie, Hannover and Koln) have changed
their endodontic concept by totally changing from hand instrumentation to
NiTi les with endomotors for the past 3 years, with great success [44,45].
The combination of the use of contemporary available modern devices and
les with a solid base of anatomic and biologic knowledge will lead to
a predictable higher quality of root canal treatment on a broader basis, thus
helping to preserve more teeth for more years in the mouth.
References
[1] Buehler WH, Gilfrich JV, Wiley RC. Eect of low temeperature phase changes on the
mechanical properties of alloys near composition TiNi. J Appl Phys 1963;34:14757.
[2] Buehler WJ, Wang FE. A summary of recent research on the Nitinol alloys and their
potential application in ocean engineering. Ocean Eng 1968;1:10520.
[3] Buehler WJ, Cross WB. 55-Nitinol unique wire alloy with memory. Wire J 1969;2:419.
[4] Thompson SA. An overview of nickel-titanium alloys used in dentistry. Int Endod J 2000;
33:297310.
[5] Civjan S, Huget EF, DeSimon LB. Potential application of certain nickel-titanium
(Nitinol) alloys. J Dent Res 1975;54(1):8996.
[6] Schafer E. Metallurgie und Eigenschaften von Nickel-Titan-Instrumenten zur maschinellen
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[7] NiTi Smart Sheet. West Chester, PA: Johnson Matthey, Inc. Available at: http://
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[8] Sedgley CM, Messer HH. Are endodontically treated teeth more brittle? J Endod 1992;18:
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[9] Craig RG, Peyton FA. The microhardness of enamle and dentin. J Dent Res 1958;37:6618.
[10] Serene TP, Adams JD, Saxena A. Nickel-titanium instruments. Application in endodontics. St. Louis (MO): Ishiyaku Euro-America; 1995.
[11] Schafer E. Wurzelkanalinstrumente fur den manuellen Einsatz. Schneidleistung und
Formgebung gekrummter Wurzelkanalabschnitte. Berlin: Quintessenz; 1998.
[12] Canaldi-Sahli C, Brau-Aguade E, Sentis-Vilalta J. The eect of sterilization on bending
and torsional properties of K-les manufactured with dierent metallic alloys. Int Endod J
1998;31:4852.
[13] Aten JC. The simulation of clinical corrosion of endodontic les [masters thesis]. Chicago:
Northwestern University of Chicago; 1993.
[14] Sarkar NK, Schwaninger B. The in vivo corrosion of Nitinol wire [abstract]. J Dent Res
1980;59A:528. Abstract 1035.
[15] Clinard K, von Fraunhofer JA, Kuftinec MM. The corrosion susceptibility of modern
orthodontic spring wires [abstract]. J Dent Res 1981;60A:628. Abstract 1277.
[16] Rondelli G, Vicentini B. Localized corrsion behaviour in simulated human body uids of
commercial Ni-Ti-orthodontic wires. Biomaterials 1999;20:78592.
[17] Edie JW, Andreasen GF, Zaytoun MP. Surface corrosion of Nitinol and stainless steel
under clinical conditions. Angle Orthod 1981;51:31924.
[18] Mayhew MJ, Kusy RP. Eects of sterilization on the mechanical propeties and the surface
topography of nickel-titanium arch wires. Am J Orthod Dentofac Orthop 1988;93:2326.
[19] Smith GA, von Fraunhofer JA, Casey GR. The eect of clinical use and sterilization on
selected orthodontic arch wires. Am J Orthod Dentofac Orthop 1992;102:1539.
[20] Kapila S, Haugen JW, Watanabe LG. Load-deection characteristics of nickel-titanium
alloy wires after clinical recycling and dry heat sterilization. Am J Orthod Dentofac Orthop
1992;102:1206.
[21] Yared GM, Bou dagher FE, Machtou P. Cyclic fatigue of ProFile rotary instruments after
clinical use. Int Endod J 2000;33:2047.
[22] Briseno Marroquin B, Willershausen B. Inuence of dierent sterilisation procedures on
the bending moment of stainless steel and nickel titanium root canal instruments [abstract].
J Endod 1999;25:288. Abstract OR23.
[23] Rapisarda E, Bonaccorso A, Tripi TR, Condorelli GG. Eect of the sterilization on the
cutting eciency of rotary-nickel-titanium endodontic les. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1999;88:3437.
[24] Busslinger A, Sener B, Barbakow F. Eects of sodium-hypochlorite on nickel-titanium
LightSpeed instruments. Int Endod J 1998;31:2904.
[25] Schafer E. Eect of sterilization on the cutting eciency of PVD-coated nickel-titanium
endodontic instruments. Int Endod J 2002;35:86772.
[26] Basketter DA, Briatico-Vangosa G, Kaestner W, Lally C, Bontinck WJ. Nickel, cobalt and
chromium in consumer products: a role in allergic contact dermatitis? Contact Dermatitis
1993;28:1525.
[27] Putters JL, Kaulesar SuKul GM, de Zeeuw GR, Bijma A, Besselink PA. Comparative cell
culture eects of shape memory metal (nitinol), nickel and titanium: a biocompatibility
estimation. Eur Surg Res 1992;24:37882.
[28] Ryhanen J. Biocompatibility evaluation of nickel-titanium shape memory alloy
[dissertation]. Oulu, Finland: University of Oulu; 1999.
[29] Wildey WL, Senia S. A new root canal instrument and instrumentation technique:
a preliminary report. Oral Surg Oral Med Oral Pathol 1989;67:198.
[30] Hulsmann M. Wurzelkanalaufbereitung mit Nickel-Titan-Instrumenten. Ein Handbuch.
Berlin: Quintessenz; 2002.

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[31] Baumann MA. RaCe-System. In: Hulsmann M, editor. Wurzelkanalaufbereitung mit


Nickel-Titan-Instrumenten. Ein Handbuch. Berlin: Quintessenz; 2002. p. 12938.
[32] Baumann MA. ProTapereine neue Generation von NiTi-Feilen. Endodontie 2001;10(4):
35164.
[33] Clauder T, Baumann MA. ProTaper. Dental Clin N Am 2004.
[34] Turpin YL, Chagneau F, Bartier O, Cathelineau G, Vulcain JM. Impact of torsional and
bending inertia on root canal instruments. J Endod 2001;27:3336.
[35] Baumann MA. Working with the FlexMaster system. Endod Prac 2003;6(2):1320.
[36] McSpadden J. Ramications of design considerations. Endodontie J 2003;2:2831.
[37] Lee DH, Park B, Saxena A, Serene TP. Enhanced surface hardness by boron implantation
in nitinol alloys. J Endod 1996;22:5436.
[38] Rapisarda E, Bonaccorso A, Tripi TR, Fragalk I, Condorelli GG. The eects of surface
treatments of nickel-titanium les on wear and cutting eciency. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2000;89:3638.
[39] Rapisarda E, Bonaccorso A, Tripi TR, Fragalk I, Condorelli GG, Torrisi L. Wear of
nickel-titanium endodontic instruments evaluated by scanning electron microscopy: eect
of ion implantation. J Endod 2001;27:58892.
[40] Tripi TR, Bonaccorso A, Rapisarda E, Tripi V, Condorelli GG, Marino R, et al.
Depositions of nitrogen on NiTi instruments. J Endod 2002;28:497500.
[41] Tripi TR, Bonaccorso A, Condorelli GG. Fabrication of hard coatings on NiTi
instruments. J Endod 2003;29:1324.
[42] Torrisi L. Ion implantation and thermal nitridation of biocompatible titanium. Biomed
Mater Eng 1996;6:37988.
[43] Schafer E. Eect of physical vapor deposition (PVD) on cutting eciency of nickeltitanium les. J Endod 2002;28:8002.
[44] Baumann MA, Roth A. Eect of endodontic skill on root canal preparation with
ProFile.04. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:7148.
[45] Sonntag D, Guntermann A, Kim SK, Stachniss V. Root canal shaping with manual
stainless steel les and rotary NiTi les performed by students. Inte Endod J 2003;36:
24655.

Dent Clin N Am 48 (2004) 6985

The ProFile system


Yeung-Yi Hsu, DDS, MS1,a,*,
Syngcuk Kim, DDS, MPhil, PhD, MD(hon)b
a

Private Practice, 11F, No. 9, Lane 81, Chung-shan N. Road, Sec.


7 Shihlin District, Taipei 111, Taiwan
b
Department of Endodontics, School of Dental Medicine, University of Pennsylvania,
240 South 40th Street, Philadelphia, PA 19104-6030, USA

Since the introduction of nickeltitanium (NiTi) to endodontics in 1988,


NiTi hand les and rotary instruments have become popularized because of
their superiority in managing curved canals. The NiTi les have the unique
properties of superelasticity and shape memory [1]. The superelasticity of
NiTi allows deformation of as much as 8% strain to be fully recoverable, in
comparison with a strain of less than 1% for stainless steel. When the stress
decreases or stops, NiTi alloy will spring back to its original shape without
permanent deformation [1,2]. The ProFile instruments made by Tulsa
Dental (Tulsa, Oklahoma) were the one of the rst NiTi instruments on the
market. In 1994, the rst product of the Pro Series 29 (Tulsa Dental)
stainless steel and NiTi hand instruments with a 0.02 taper was marketed.
The manufacturer soon developed rotary counterparts due to the canalcentering capacity and less aggressive cutting of NiTi. Further developments
included increasing taper, including ProFile Series 29 0.04 taper, 0.06 taper
rotary instruments, and Orice Shapers. The 0.04 taper instruments were
initially designed for the carrier-based obturation technique. The 0.06 taper
instruments were developed for those clinicians who preferred a fuller canal
preparation than could be obtained using a 0.04 taper. The Orice Shapers
system comprised six instruments with a shorter working blade and larger
taper. These instruments were designed to provide continuous shape in the
coronal parts of root canals. In 1996, Dr. Stephen Buchanan proposed
a series of even larger taper hand les named Greater Taper (GT) les. GT
les had 0.06, 0.08, 0.10, and 0.12 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, School of Dental Medicine, University of
Pennsylvania, PA, USA
* Corresponding author.
E-mail address: yyhsutw@yahoo.com.tw

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.11.006

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Y.-Y. Hsu, S. Kim / Dent Clin N Am 48 (2004) 6985

engaging the wall [3]. After the merge of the Tulsa Dental and Dentsply
companies in 1998, GT rotary instruments and ProFile 0.04 taper and 0.06
taper with International Standards Organization (ISO)-sized tips were
marketed. The ProFile ISO-sized tip system was more popular in Asia and
Europe. Today, the ProFile system is one of the best-selling rotary instrument
systems in the world. The following section thoroughly reviews this system.
Unique le design
Cross-sectional geometry
The ProFile instrument family, including Prole 0.04 and 0.06 taper,
Orice Shapers, and GT les, all have the same cross-sectional geometry.
The shape is made by machining three equally spaced U-shaped grooves
around the shaft of a taper NiTi wire. There is a central parallel core inside
that may account for the enhanced exibility compared with Quantec
(Tycom, Irvine, California) [4] and ProTaper (Dentsply International, York,
Pennsylvania) [5], which possess a tapered central core. It has a 20 negative
rake angle at the cutting edge and at radial lands to cut dentin in a planing
motion. These congurations prevent the instrument from screwing into
the canal while rotating. The radial lands also add peripheral mass that
contributes signicantly to the strength of the instrument. The U-shaped
grooves provide the space to accommodate dentin shavings while planing of
the canal wall. The 20 helical angle was designed to remove the shaving
debris coronally while the instrument rotates clockwise.
Every ProFile le has a bullet-nosed tip with a rounded transition angle.
This noncutting tip will follow a pilot hole and guide the instrument into the
canal. The noncutting tip and symmetric radial lands design allow the le to
remain self-centered as it rotates through 360 , theoretically decreasing the
potential for canal transportation and procedural errors to occur [6,7].
Series 29
The rate of increase between le sizes in this series is at a constant of
29%. It is claimed that fewer instruments are required to enlarge to master
apical le size. Table 1 shows the size equivalents of Series 29 instruments
compared with ISO sizing. In contrast to a 50% size increase between ISO
size 10 and size 15 and a 33% increase between size 15 and size 20, the 29%
increment has the advantage of smooth transition among the smaller sizes.
There is a much greater leap of size increment in larger les, however, which
may create diculties and complications while shaping curved canals [3].
The ProFile system with increased tapers has been developed in the hope
that the greater are along the instrument shaft would automatically create
the divergence required for obturation. The taper of the instrument aects
the increase in diameter along its length. In a standard 0.02 taper le, the
diameter increases by 0.02 mm per millimeter from the tip (D0). Thus, D16,
which is the le diameter 16 mm away from D0, is 0.32 mm wider than D0.

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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

0.129
0.167
0.216
0.279
0.360
0.465
0.600
0.775
1.000

For a 0.04 taper instrument, D16 is 0.64 mm wider than D0, and for a 0.06
taper instrument, D16 is 0.96 mm wider than D0 [3,8].
The GT le has a xed D0 diameter of 0.20 mm and a xed maximal ute
diameter of 1.0 mm. As such, dierent degrees of taper account for dierent
lengths of blade.
Clinical performance
The clinical performance of the ProFile system in general is rated good
and is comparable to other NiTi rotary systems [4,7,9]. For a more detailed
discussion, the clinical performance of the ProFile system is divided into the
following sections: cutting/machining eciency, shaping ability, cleaning
ecacy, and eect of NaOCl and sterilization.
Cutting/machining eciency
Machining eciency has been dened as the procedure of removal of
simulated canal/tooth substance with the uted material. Machining
eciency has been shown to relate to the alloy used and to cross-sectional
geometry [10]. Hakel and colleagues [11] dened cutting eciency as the
mass of Plexiglass cut per unit of energy used by the test le. Hakel and
other investigators [11,12] found that the NiTi les cut less eciently than
stainless steel les. This reduction in eciency may be explained by the fact
that NiTi has a very low modulus of elasticity and, thus, deformation on
contact with simulated canal/tooth substance is induced. Kazemi et al [13]
demonstrated that NiTi les are comparable with or better than stainless
steel les in terms of machining dentin. The divergent results may be due to
the dierent behavior of les when cutting Plexiglass and dentin substrate.
Dr. Johnson [14] classied all rotary instruments as having active,
semiactive, or passive cutting blades. The ProFile system ts into the category
of passive instruments. The slight negative rake angle and radial lands make
the les cut less aggressively than those having active cutting blades (eg,
ProTaper [15], HERO 642 [Micro-Mega, Besancan, France], RaCe File [FKG

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Y.-Y. Hsu, S. Kim / Dent Clin N Am 48 (2004) 6985

Dentaire, Switzerland], Pow-R [Moyco Union Broach, York, Pennsylvania])


and those having semiactive cutting blades (eg, Quantec [14,16]).
Shaping ability
Several studies have conrmed the ability of rotary NiTi les to stay
centered [17,18] and to maintain canal curvature better than stainless steel
hand les [1921]. Thompson and colleagues [6,7,9,22] presented a series of
studies on the shaping ability of ProFile 0.04 taper Series 29 and ISO-sized tip
using simulated root canals of dierent curvatures and shapes. None of the
canals became blocked with debris in either system. The loss of working
length averaged 0.5 mm or less. Intracanal impressions of prepared canal
demonstrated that most canals had denitive apical stops, smooth canal
walls, and good ows and tapers. Despite their superelastic property, NiTi
instruments still tended to straighten within the canals. Several canal
aberrations such as zips, elbows, and transportations could be seen on the
impressions. Similar phenomena were also found in extracted human teeth
[4]. Therefore, not only the ProFile system but also all NiTi instruments must
be used with caution when larger sizes and greater taper les encounter
severely curved canals.
The instrumentation time required for NiTi rotary instruments is
generally less than for stainless steel hand les [8,1921]. Because fewer
instruments are used in the ProFile system, even less instrumentation time is
required compared with the LightSpeed (LightSpeed Inc., San Antonia,
Texas) and Quantec systems [18,23]. Less instrumentation time could
further reduce operator and patient fatigue.
Cleaning eciency
Numerous studies in the literature have established the role of bacteria and
their by-products in the pathogenesis of apical periodontitis. The ultimate goal
of endodontic treatment is to prevent or eliminate infection within the root
canal system [24]. Classic series of studies regarding antibacteriologic eects of
the individual steps in endodontic procedure were performed by Bystrom and
Sundqvist [2426] using stainless steel hand les. Dalton et al [27] demonstrated
that the amount of bacterial reduction after ProFile rotary instrumentation
was comparable to stainless steel hand les when saline was used as an irrigant.
There was a substantial bacterial reduction with progressive ling to larger
sized les. Completion of NiTi instrumentation yielded 28% negative culture
samples [27]. The result was comparable to rstavik et als [28] study in which
no detectable bacterial growth in 43% of teeth immediately after extensive
apical reaming with saline irrigation was found.
Adding 1.25% sodium hypochlorite (NaOCl) as an irrigant further
increased the percentage of negative culture to 61.9%. NaOCl, however,
requires an appropriate apical size (ProFile Series 29 size 5 and above) to
become eective in bacterial reduction [29,30]. This indicates that NaOCl

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73

irrigation is an important step in the reduction of canal bacteria during


rotary instrumentation. Mechanical instrumentation with NaOCl irrigation,
however, cannot constantly render canals bacteria-free. In the presence of
apical periodontitis, intracanal medication with calcium hydroxide for at
least 1 week is recommended. One-week calcium hydroxide medicament
could render 91.5% of canals void of bacteria [30].
Canal shaping with ProFile and other NiTi instruments usually results in
a round preparation and smear layer formation [18]. Therefore, the cleaning
ecacy of NiTi rotary instruments was questioned, especially in oval canals
such as mandibular incisors and distal roots of mandibular molars [23,31].
Peters and colleagues [31] used micro-CT to access canal geometry after
preparation with four dierent techniques, namely, GT rotary, NiTi K le,
Lightspeed, and ProFile 0.04 taper. They demonstrated that approximately
35% to 40% of the canal surface remained untouched after complete
instrumentation. This nding proved the necessity of using chemical irrigant
to dissolve tissue debris and smear layer while undergoing canal preparation
with rotary instruments. The debris score and smear layer score after
ProFile instrumentation were reported to be signicantly lower in the 2.5%
NaOCl/17% EDTA group than in the tap water group [31].
Eect of NaOCl and sterilization on ProFile
Corrosion was the major concern regarding NaOCl irrigation while using
NiTi instruments. Chloride corrosion can leave micropitting on instrument
surfaces and lead to areas of stress concentration and crack formation.
Hakel et al [11,32] showed that after 2.5% NaOCl treatment for 12 and
48 hours, there was no signicant change in the mechanical properties of
ProFile instruments. The cutting eciency also was not aected by the
presence of NaOCl. Yared et al [33,34] also demonstrated that when ProFile
rotary instruments were used on extracted teeth, irrigation with 2.5% NaOCl
did not lead to a decrease in the number of rotations to breakage of the les.
Sterilization had been suggested as a way to rejuvenate NiTi les by
reversing the stress-induced martensite transformation to the austenite
phase [35]. Yared et al [33,34] demonstrated that sterilization by dry heat or
steam autoclave did not shorten the lifespan of ProFile 0.06 taper ISO-sized
tip les. According to the results of their studies, the ProFile 0.06 taper ISOsized tip les could be safely used up to 10 times in vitro or for four molars
in vivo. Silvaggio and Hicks [36] also proved that sterilization of ProFile
0.04 taper les in dry heat, steam autoclave, or satim autoclave sterilizer up
to 10 times does not increase the likelihood of fracture.

Safety concerns
Although NiTi rotary instruments have the advantages of superelasticity,
shape memory, and good eciency with less fatigue, their use does have

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Y.-Y. Hsu, S. Kim / Dent Clin N Am 48 (2004) 6985

safety concerns including loss of tactile sensation, extrusion of debris, and


instrument deformation and failure.
Loss of tactile sensation
When using rotary instruments compared to hand les, there appears to be
a dierence in tactile awareness. There is less feedback from rotary
instruments, particularly regarding the direction of the curvature and location
of apical terminus. Even with the design of radial lands, larger sized ProFile
instruments with greater taper such as the ISO size 35, 0.06 taper le still tends
to thread into the canal [37]. Therefore, length determination before use of
rotary instruments is essential. Properly angulated radiographs and an
electronic apex locator are necessary. Prearing the canal orice facilitates
more accurate and consistent reading of working length [38,39]. After the
length is obtained, the clinician should keep this length while operating the
rotary instruments. If the le threads in, then the clinician should not stop the
instrument rotating, but should try to withdraw the le while still rotating or
reverse the direction of rotation to drive the le out of the canal.
Extrusion of debris
When endodontic therapy is performed, mechanical and chemical irritants
may be inadvertently introduced into periradicular tissue and cause postinstrumentation are-ups. Problems with debris extrusion using the ProFile
rotary system were investigated by Hinrichs et al [40] and Reddy and Hicks
[41]. They demonstrated that the amount of debris extruded with ProFile les
was comparable to the balanced-force technique using ex-R les but was
signicantly less than the step back technique using hand K les. The lesser
amount of debris extruded may be due, in part, to the ute design of ProFile
instruments that aids in debris removal, and to the reaming motion of the
ProFile rotary system and the balanced-force technique that extrudes less
debris than the push-pullmotion of manual stepback technique. The
amount of debris extrusion was positively related to the amount of irrigant
extruded but irrelevant to canal length, curvature, and foramen size [40].
Instrument deformation and failure
Intracanal instrument separation is the most frustrating mishap that
occurs when operating the NiTi rotary system. Breakage of NiTi
instruments can occur without any visible sign of unwinding or permanent
deformation. Therefore, visual examination is not a reliable method for
evaluation of used NiTi instruments [42]. The clinician must recognize the
risk factors to prevent separation from occurring.
There are two modes of failure that cause rotary instrument separation;
namely, torsional and exural fractures. Torsional fracture occurs when the

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75

torque limit of the instrument is exceeded. Flexural fracture arises from


minute surface defects and occurs after cyclic fatigue [43,44]. As an
instrument rotates in the canal, it binds against tooth structure, which places
friction on the instrument called torque. The amount of torque generated
while rotating in the canal is positively related to the mass of the instrument.
Larger sized and greater taper les, although being stronger and having
better torque resistance, will create more torque value on contact with the
canal wall [14,45]. Radius of canal curvature is the most important factor in
determining the torque value. If two canals have the same angle of curvature
but have a dierent radius, then the one with smaller radius has the more
abrupt canal deviation and results in higher torque on le. Torque also will
rise with increased apical force. 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]. When using instruments
of greater taper, the rst thing to cut is the coronal portion of the canal.
As the instrument goes deeper into the canal, the torque increases as
a consequence of the increased contact area between the le and dentinal
wall. Therefore, when the le advances further into the canal, the pressure
should be lessened to prevent torque from building up [14]. Use of a
lubricant within the canal can reduce the friction between the instrument
and canal wall. Avoidance of torque failure requires maintaining adequate
lubrication during instrumentation [14].
Cyclic fatigue is synonymous with metal fatigue. When an instrument is
rotating around the curve, it is compressed on the inner side of the curve
and stretched on the outer side of the curve. With every 180 of rotation,
the instrument exes and stretches over and over again, resulting in cyclic
fatigue and, eventually, fractures [14]. The larger sized or greater taper le
sustains more compressive and tensile forces due to increased metal mass.
Therefore, cyclic fatigue will occur more quickly. The radius of curvature is
likely the primary reason for instrument separation due to cyclic fatigue. A
smaller radius with an abrupt curve induces greater fatigue than a lager
radius with a sweeping curve [14].
In a relatively straight or a gently curved portion of a canal, the clinician
should select an instrument with high strength to prevent torsional fracture.
Therefore, using a larger diameter instrument such as 0.06 taper rather than
0.04 or 0.02 taper will provide more torque resistance. When encountering
a sharp apical curve, the most appropriate choice would be a 0.02 taper le
for its least susceptibility to metal fatigue. If the curvature is somewhat in
between the two aforementioned conditions, then problems with torsional
fracture and cyclic fatigue need to be considered. Consequently, an
intermediate taper such as 0.04 taper, which has more torque strength than
0.02 taper yet is less susceptible to cyclic fatigue than a 0.06 taper or a GT
le, should be selected [14].
To prevent intracanal breakage of instruments, gaining straight line access
(coronal and radicular) is the rst step in obtaining an uninhibited path for the

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Y.-Y. Hsu, S. Kim / Dent Clin N Am 48 (2004) 6985

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

Clinical applications
Cleaning and shaping of the root canal system
The fundamental concepts for cleaning and shaping of a root canal system
remain the same regardless of the techniques and instruments used. Obtaining

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77

a straight line access into the orice and canal is the rst critical step for
successful outcome. Any overhanging dentins from the chamber roof and
cervical ledges near the orices have to be removed. The preparation should be
extended to eliminate any coronal interference during subsequent instrumentation [3]. After the coronal access is completed and canal orices are identied, the chamber is debrided by copious irrigation with NaOCl. Ultrasonics
and chelating agents such as EDTA also can be used before canal preparation.
Pre-enlargement of the coronal two thirds of the canal has mechanical
and biologic benets. Mechanically, pre-enlargement allows early removal
of coronal interferences, thus aiding in better tactile sensation of the le
moving apically. It also minimizes canal deviation and instrument separation by reducing contact with the canal. Biologically, pre-enlargement
facilitates rapid removal of contaminated tissue from the canal system and
improves the penetration of irrigation solution. It minimizes extrusion of
debris apically and subsequent post-treatment are-ups [38]. Prearing also
provides more accurate and consistent working length determination [39]
and, therefore, more precise canal cleaning and shaping. Also, obturation
can be accomplished without violating surrounding periradicular tissue.
Pre-enlargement of the coronal two thirds can be accomplished with
a variety of instruments such as Gates-Glidden (GG) burs, Orice Shapers,
GT les, and any NiTi rotary system with greater tapers in either crown
down or step back manner. Dr. Ruddle [3] suggested using NiTi rotary les
in a crown-down technique or GG burs in a stepback technique to complete
coronal preparation. The author prefers using GG burs in a crown down
direction, with GG bur 4 submerging the cutting head below the orice and
each smaller GG stepping into canal for about 2 to 3 mm until reaching the
predetermined depth. No matter what instrument or what sequence is
selected, it is important to insert a stainless steel hand le (0.02 taper, size 10,
size 15) to the level at least 2 mm deeper than the desired depth for the
rotary instruments. The advantages for such a procedure are twofold. First,
it gives information about canal anatomy regarding to the curvature and
width. Second, it creates a patent pathway for the rotary instruments. The
reason for hand les to reach the level 2 mm beyond the rotary instrument is
to preserve the most apical canal anatomy for future hand le advancement.
The goals for pre-enlargement are to relocate the canal away from the
anatomic danger zone and to achieve uninhibited access to the apical third
of the canal, yet still preserve enough root structure for prosthetic restoration. The entire pre-enlargement procedure should be done with copious
irrigation and frequent recapitulation to ensure canal patency [3,38].
After pre-enlargement of the coronal two thirds, the clinician is ready to
advance the stainless steel hand le to the apical terminus. The clinician
should mentally picture the canal anatomy before use of rotary instruments.
In cases where canals merge (Weines classication type II), canals divide
(Weines classication type IV), and in bayonet-shaped canals, NiTi rotary
instruments will bind to the dentinal wall and fracture. Therefore, these

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Y.-Y. Hsu, S. Kim / Dent Clin N Am 48 (2004) 6985

dicult anatomies are better nished with hand instrumentation. Accurate


working lengths can be obtained from well-angulated radiographs and an
electronic apex locator [39]. The apical extension of working length and the
nal apical preparation size have long been debated. Although the
philosophies may vary, the principles remain the same. Only after a patent
pathway to the terminus is established by using small hand les should the
clinician start nishing the apical preparation with a rotary instrument.
ProFile and other NiTi rotary instruments will perform optimally with less
breakage when used with the recommended speeds and correct sequences.
Whether the sequence is from large to small or vice versa (Boxes 1, 2) may
not be critical, so long as the instruments are used passively within the canal.
The clinician should keep the instrument rotating before entering the orice
and use a short-distance pecking motion to advance the le apically. If
resistance is confronted, then the le should be withdrawn while rotating.
Several possibilities exist for the resistance of apical movement. The most
likely cause is encountering curvature; however, the instrument tip may be
too big to follow the pathway established by the small hand le. In either
case, removal of coronal interferences with a larger le set at a shorter
distance or enlargement of the pathway with a smaller le will aid in le
advancement. Another possibility for resistance is intracanal or interblade
debris accumulation. Copious irrigation with recapitulation or wiping the
debris o the le with wet gauze or a sponge will resolve the problem.
Obturation
After complete cleaning and shaping of the root canal system, the
obturation procedure can be proceeded when no subjective symptoms or

Box 1. Recommended sequences for use of ProFile by


manufacturer
1. Estimate the working length of the canal from a preoperative
radiograph.
2. Create a glide path with a size 10/15 stainless steel K file.
3. Use Orifice Shapers sizes 4, 3, 2, and 1 in the coronal one third
based on canal size and angle of pathway.
4. Perform crown-down preparation: use ProFile instrument of
taper/size 0.06/30, 0.06/25, 0.04/30, and 0.04/25 to resistance
(0.06/35, 0.06/30, 0.04/35, and 0.04/30 for larger canal).
5. Determine the working length with size 15 K file.
6. Perform apical preparation with ProFile taper/size 0.04/25,
0.04/30.
7. Finish with ProFile taper/size 0.06/25 short of working length to
blend the coronal and apical preparation.

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79

Box 2. Possible sequences for use of ProFile


1. Estimate the working length of the canal from a preoperative
radiograph.
2. Create a glide path with a size 10/15 stainless steel K file.
3. Use GG burs 4, 3, 2, and 1 in the coronal two thirds based on
canal size and angle of pathway.
4. Determine the working length with size 15 K file.
5. Perform hand instrumentation with taper/size 0.02/15, 0.02/20
stainless steel K file to working length.
6. Perform apical preparation with ProFile taper/size 0.06/25,
0.06/30.
7. Finish with ProFile taper/size 0.06.35 short of working length to
blend the coronal and apical preparation.

signicant infections exist. There is no one particular obturation technique


that is superior to others for those canals prepared with ProFile systems.
Any technique in which a clinician is procient can be used for NiTi
instrumentprepared canals. Figs. 13 provide some examples of endodontics performed with 0.04 and 0.06 taper ProFile instruments. The
manufacturer advocates packages that combine rotary les and integrated
obturation systems such as ProFile 0.04 taper and Thermal, or GT les
and corresponding GT obturators. Vertical compaction of warm guttapercha using traditional Schilders technique or the continuous wave
technique achieves good clinical results. The canal preparation by ProFile
provides good taper and smooth ow, thus allowing uneventful plugger
penetration and gutta-percha ow. The obturation quality and eciency of
the cold lateral compaction technique were evaluated by Hembrough et al
[51] after canal preparation with 0.06 taper ProFile les. Three dierent
master cones with dierent degrees of taper were chosen; namely, a 0.06
taper gutta-percha cone, a customized point from nonstandardized master
cone, and an ISO standardized cone. There was no signicant dierence in
terms of obturation quality; however, the use of greater taper cones such as
0.06 taper cones and customized cones was more ecient than the ISO
standardized cones because less accessory points were used [51].
Retreatment
ProFile instruments rotating at higher speeds are very eective tools for
removing intracanal gutta-percha. The gutta percha near the orice area is
generally the tightest part, which can be removed by GG burs or by heat. The
clinician should select two to three appropriately sized ProFile instruments
that t passively in the canal in a crown-down manner. The recommended
speed for gutta-percha removal ranges between 1200 and 1500 rpm. The

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Fig. 1. (A,B) Prepared with 0.06 taper ProFile in a gently curved maxillary second molar.

friction generated by ProFile instruments can soften the gutta percha and
move it coronally [52]. Baratto and colleagues [53] evaluated the eectiveness
of the ProFile 0.04 taper to remove gutta-percha. They found that ProFile
could reach ideal working length rapidly regardless of the obturation
techniques but was inadequate in complete removal of gutta-percha. To
ensure the complete removal of gutta percha, the clinician might use ProFile
to remove the bulk of gutta-percha, thus providing space for chemical
solvent. With the aid of a microscope, the clinician can try to wipe or wick
out the residual gutta percha from the canal aberrations with paper points.
Summary
NiTi rotary instruments have advanced endodontics into another era.
The ProFile rotary instrument system has good clinical performance in
managing curved canals and has proved to be more ecient than hand
instrumentation. Our professional responsibilities include making the best
use of this system and providing the best quality of care to our patients.

Y.-Y. Hsu, S. Kim / Dent Clin N Am 48 (2004) 6985

81

Fig. 2. (AC) Prepared with 0.04 taper ProFile in a moderately curved mandibular second
molar. Noted that a separated #10 K hand le in the apical third of distal canal, which was
bypassed and lled to the apex.

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Y.-Y. Hsu, S. Kim / Dent Clin N Am 48 (2004) 6985

Fig. 3. Prepared with 0.06 taper ProFile.

There is a learning curve before prociency and ProFile use must follow the
principles listed below [3]:
1. Coronal and radicular straight line access are essential to proper
cleaning and shaping and to reduce risk of instrument separation.
2. Always use hand instrument to explore canal anatomy and obtain
a pathway before introducing rotary instruments.
3. Adhere to the recommended rotational speed. For an inexperienced
operator, following the sequences provided by the manufacturer may
result in less frustration. Practice on the extracted teeth before use in
vivo.
4. Make sure to always have enough lubrication in the canal and work
passively on rotary les. Never force the instrument to advance
apically.
5. Understand the limitation of NiTi rotary instruments. Dicult canal
anatomy such as canal merge, abrupt curvature, and bayonet-shaped
canals may not be appropriate for their use.

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83

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and eciency between rotary endodontic instruments driven at 150 rpm and 350 rpm.
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with nickel titanium rotary instruments: an evaluation of the use of three dierent master
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Pathways of the pulp. 8th edition. St. Louis (MO): Mosby; 2002. p. 875929.
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re-treatment of gutta-percha-lled root canals. Int Endod J 2002;35:6514.

Dent Clin N Am 48 (2004) 87111

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 Koln, 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. Cliord
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 les demonstrate completely new design features.
The progressively tapered instruments with their new ute 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 rst rotating nickel-titanium les for the preparation of
root canal systems in endodontics, a wide range of new le systems have
been established in the market. The benets of the new systems are apparent
in their near-perfect preparation of the root canal system. Properly used,
NiTi systems enable the user to nish a more predictable root canal
instrumentation and limit procedural errors at the same time. The latest
research [2,3] seems to conrm the fact that NiTi les 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 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.10.006

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T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87111

Originally, NiTi ProTaper instruments were developed to facilitate


instrumentation of dicult, constricted, and severely curved canals (Fig. 1).
A revolutionary new le geometry was designed to allow for high eciency
and safety. Since the introduction of the system, the continuing application
has allowed for the safe and ecient management of even standard-cases
(Fig. 2). The ProTaper instruments were designed to cover the whole range
of treatment with only a few les, which incorporate superior exibility,
unmatched eciency and improved safety [1]. The number of les with
a progressive taper (ProTaper) was decreased to a set of six instruments
(Fig. 3): three shaping les for the crown-down procedure and three
nishing les for apical shaping and creating a smooth transition from the
middle one third of the canal providing the preparation deep shape. The
three shaping les 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 nishing les are
dominated by dierent diameters, #20, #25, #30 and a xed taper over 3 mm
to nish 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) 87111

89

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

The following innovations characterize the ProTaper system:


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

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T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87111

Fig. 3. The set of six ProTaper les includes three shaping les and three nishing les.

comparison with other le systems manufactured by Dentsply/Maillefer


(Prole and System GT) as well as other le systems with radial lands and
a U-shape design, ProTaper instruments demonstrate a new convex,
triangular cross-section (Fig. 6). This design results in a reduced contact
area between dentin and the cutting blade of the instrument, achieving

Fig. 4. Scanning electron microscope (SEM) picture demonstrating the modied guiding tip
of a ProTaper le. (From Baumann MA. ProTapera new generation of NiTi-les in
endodontics. Endodontie 2001;10:353; with permission.)

T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87111

91

Fig. 5. SEM picture demonstrating the cutting blades of a ProTaper le. (From Baumann MA.
ProTapera new generation of NiTi-les in endodontics. Endodontie 2001;10:353; with
permission.)

cutting eciency that was not possible previously. In the same process, it is
possible to reduce the torsional strain and ease the pressure to achieve
widening of the root canal. In comparison with other le geometries with
radial lands that produce a passive cutting and scraping action, the
ProTaper system works with an active cutting motion, which substantially
increases the eectiveness of the system and reduces torsional strain [4].
Regarding instrument geometries, only F3 has a reduced cross-section with
a U-shape to facilitate a higher degree of exibility (Figs. 7 and 8).

Fig. 6. SEM picture demonstrating the convex, triangular cross-section of the ProTaper les.
(From Baumann MA. ProTapera new generation of NiTi-les in endodontics. Endodontie
2001;10:353; with permission.)

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Fig. 7. SEM picture demonstrating the cutting blades of F3 with a reduced core. (From
Baumann MA. ProTapera new generation of NiTi-les in endodontics. Endodontie
2001;10:353; with permission.)

Furthermore, new design features are the variable helical angel and
balanced pitches in the instrument, which improve cutting action, allow for
better removal of debris out of the root canal, and prevent the instrument
from screwing into the canal. The length of the le handle of the instruments
was reduced from 15 mm to 12.54 mm to allow for better access in dicult

Fig. 8. SEM picture demonstrating the cross-section of F3 with a reduced core. (From
Baumann MA. ProTapera new generation of NiTi-les in endodontics. Endodontie
2001;10:353; with permission.)

T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87111

93

Fig. 9. This graphic model, overlapping the taper of ProTaper instruments, shows the complex
design of the instruments.

posterior areas, which could compromise the treatment result. The les are
available in 21- and 25-mm lengths.
Instrument design
Shaping les
The ProTaper system features six NiTi les, the rst of which is the
auxiliary shaping le, called Shaper X or SX. SX is recognized by its lack of an
identication ring on its handle and its extraordinary shape, reminding Prof.
Pierre Machtouone of the three specialists involved in the development of

Fig. 10. Straight-line access is of major importance, especially in complex canal systems such as
the obturated c-shaped lower molar. (Courtesy of Thomas Clauder, DDS.)

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T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87111

Fig. 11. The le in the unshaped canal gives information about the angulation of the coronal
part of the canal. (Courtesy of Cliord J. Ruddle, DDS.)

the systemof the Eiel Tower in Paris (see Fig. 3). SX is available with
cutting blades of 14 mm and a tip diameter of 0.19 mm. All of the ProTaper
shaping les have a progressively increasing taper; SX has the highest
increase. At D6, D7, D8, and D9, the cross-sectional diameter increases from
0.50 mm, 0.70 mm, 0.90 mm, and 1.10 mm, according to a taper of 11%,
14.5%, 17%, and 19%, respectively. The total increase of taper in SX from D0
to D9 is dened with nine dierent tapers from 3.5% to 19%.

Fig. 12. With brushing motions, the canal orice has to be relocated to achieve straight-line
access to the apical region of the canal. (Courtesy of Cliord J. Ruddle, DDS.)

T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87111

95

Fig. 13. Shaping with SX leads to removal of the overlapping dentin walls and allows for
straight-line access. (Courtesy of Cliord J. Ruddle, DDS.)

The complex le design allows for ideal and ecient shaping of the
coronal aspects of the root canal and the relocation of canal orices,
resulting in a straight-line access. The relocation of the canal orices should
be in the direction of overhanging dentin areas and away from danger
zones in furcation areas and thinner dentin walls, where strip perforations
can compromise treatment objectives. The instrument is used in a brushing
motion and is designed to replace Gates-Glidden drills (Dentsply Maillefer,

Fig. 14. Precise determination of working length and establishing patency with hand les are
key factors for further cleaning and shaping procedures. (Courtesy of Cliord J. Ruddle, DDS.)

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Fig. 15. S1 and S2 are carried to working length, shaping primarily the coronal two thirds of
the canal, but also pre-enlarging the apical area. (Courtesy of Cliord J. Ruddle, DDS.)

Ballaigues, Switzerland). The diameter at D10 is 1.11 mm, which corresponds to a Gates-Glidden drill size of four.
Shaping le 1 (S1) has a purple identication ring and shaping le 2 (S2)
has a white identication ring on their handles (see Fig. 3). The diameter at
the tip of S1 is 0.19 mm and of S2 is 0.20 mm. Both instruments have an
increasing taper over the whole working range, although the increase is not
as aggressive as that of SX. S1 has an increasing taper from 2% on D1 to

Fig. 16. Gauging the apical canal diameter provides further information that inuences the
nishing criteria. (Courtesy of Cliord J. Ruddle, DDS.)

T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87111

97

Fig. 17. ProTaper les, used in the described sequence, engage special sections of the root canal
shown in the graphic.

Fig. 18. Radiograph showing a curved lower molar instrumented with ProTaper rotary les.
(Courtesy of Thomas Clauder, DDS.)

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T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87111

11% on D14. S2 has an increasing taper from 4% on D1 to 11.5% on D14.


S1 is designed to shape mainly in the coronal section of the root canal; in
comparison, S2 is designed to shape the middle section of the root canal
system. Because these instruments are already at working length after initial
prearing, they shape the apical region increasingly (doubling of the taper at
the instrument tip).
Finishing les
The nishing les F1, F2, and F3 are marked with a yellow, red, and blue
identication ring, respectively (see Fig. 3). Their diameters at the tip (D0)
are 0.20 mm, 0.25 mm, and 0.30 mm, respectively. All three instruments
have a xed taper in the rst 3 mm from D0 to D3. F1 has a taper of 7%, F2
has a taper of 8%, and F3 has a taper of 9% in this region. Over the
remaining length of the cutting blade, a reverse taper can be found. The
decreasing taper ensures a continuing exibility within the le and avoids
too large a diameter at the shaft area of the instrument. The instruments
have been developed for superior apical preparation, in addition to shaping
the middle section preferably. This complex and demanding instrument
design can be appreciated best when comparing the cross-sections in an
overlapping model highlighting the tapers graphically (Fig. 9) [5].

Instrumentation with ProTaper les


The ProTaper system is a preparation system that can be used for
complex and standard cases, allowing for a clean, ecient, and predictable
preparation of the root canal. The successful application of the system
demands certain preconditions.
Torque-controlled endodontic motors
Ruddle [6] has shown that with the use of rotating NiTi instruments, the
risk of instrument separation increases. These fractures often occur in the
apical portion of the root canal system, impeding adequate cleaning,
shaping, and obturation. Although the manufacturers of NiTi systems
recommend checking the les frequently to prevent possible fracture,
instruments may break without warning or any indication of a previous,
permanent, visible deformation or defect. To minimize this risk of
separation, it is recommended that inexperienced users take advantage of
torque-controlled endodontic motors [7]. Although experience and routine
is of great importance to the successful usage of the system [8], even
experienced operators can reduce the risk of separation by working with the
recommended range of torque. The use of new instruments also reduces the
risk of instrument fracture signicantly [9]. Force should never be applied to

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99

Fig. 19. ProTaper les were used for hand instrumentation to instrument the extreme curvature
of the lower molar. (Courtesy of Thomas Clauder, DDS.)

a le; only a light brushing motion should be used to achieve the desired
results.
Straight-line access
An ideal access cavity preparation is very important to successful
treatment, independent from the le system and the technique used (Fig. 10).
To avoid staining the les unnecessarily and instrumenting unnecessary
curvatures, it is necessary to achieve a straight-line access and to reduce all
overlapping dentin areas. The ProTaper SX le may be used to remove the
triangle of dentin rapidly, eectively, and safely [1,10]. Furthermore, it has
to be ensured that all orices can be viewed on the mirror without any
movement of it. In addition, access cavities should be reshaped so that
a straight-line access to apical regions can be achieved. The angle of the
inserted instrument is a good indicator: if straight-line access has been
achieved, the instrument should stand upright (Fig. 11) [1]. The angulations
after the initial crown down should be parallel to the axis of the tooth to
ensure the most eective cutting eciency in the regions of application. A
recent study showed that the ProTaper Systemlike most other rotational

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T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87111

Fig. 20. Previous endodontic treatment resulted in persisting apical periodontitis and is a source
of acute symptoms. (Courtesy of Thomas Clauder, DDS.)

systemstends to result in slight transportation, which increases when the


root canal systems show an increased initial angulation [11]. A wellprepared coronal shaping minimizes this problem and therefore is of utmost
importance to a successful result [11].
Glide path
Establishing a smooth glide path is a top priority for all endodontic
manipulations, and also is necessary for the safe use of the ProTaper
System. The ProTaper system is designed so that the lesafter initial
prearing with S1 and SXcan be carried easily to working length. A
carefully prepared glide path allows for the safe use of the instrument. The
following instruments engage dierent parts of the canal system as far as
their instrument geometry allows, and also widen the apical portion of the
canal [7].
Irrigation and chelators
The pulp chamber has to be lled with irrigating solution (NaOCl or
ethylenediaminetetraacetic acid [EDTA] solution) during the whole shaping

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101

Fig. 21. The ProTaper les also can be used for retreatment cases. This postoperative
radiograph shows the tooth after instrumentation and obturation of all four canals. (Courtesy
of Thomas Clauder, DDS.)

procedure. In addition, a viscous chelator should be used to minimize force


on the instrument. After the use of each instrument, irrigation conrming
patency and reirrigation is of main importance. One of the rst steps after
carefully preparing an ideal access cavity to working length is the initial
negotiation of the canals with a #10 or #15 K-le up to about two thirds of
the estimated working length. This is a decisive step in the use of any rotary
system, and important information can be deduced from the angle of the
canal and the conrmation of straight-line access (see Fig. 11). Additional
knowledge also can be gathered on the anatomy of the canal and potential
anatomic problems that could inuence the treatment plan, such as
conuent or dividing canals, severe curvatures, or s bends [12]. A further
aspect is the canal diameterthe procedure is inuenced substantially when
open, constricted, or complete calcied canals are present.
After a glide path has been established with K-les, S1 is the rst
instrument used. During insertion, a brushing motion against the canal wall
in the direction of repositioning the canal orice is used. This motion is
repeated a few times before removing the le from the canal. Coronal

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Fig. 22. This interesting canal anatomy was cleaned and shaped with ProTaper les. (Courtesy
of Thomas Clauder, DDS.)

shaping with SX then can be started. SX is inserted while rotating into the
root canal. If a light resistance is felt on the instrument, the le is withdrawn
and worked in a brushing motion against the dentin wall of choice (Fig. 12)
[1,6]. Repeating this procedure allows for deeper insertion of the instrument,
enabling the removal of all overlapping dentinal walls and a perfect coronal
shape of the root canal. It is important to inspect the instrument after each
use to prevent fractures of the instrument. Deformed instruments must be
discarded immediately. Shaping with SX should result in generous dentin
removal; inadequate widening of the coronal aspects of the root canal can
complicate and slow down further instrumentation, because following
instruments can get stuck in thin coronal parts of the canal. After the initial
crown down is nished, the les inserted into the root canal should be
parallel to the axis of the root (Fig. 13).
After the initial crown down, the working length is conrmed and
patency is established (Fig. 14). A #10 K-le is inserted passively into the
canal. Working length should be checked with an electronic apex locator
and conrmed with a well-angulated radiograph. Patency is of great
importance and must be maintained during the complete shaping procedure

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103

Fig. 23. Straight forward cases can be shaped without procedural errors. (Courtesy of
Thomas Clauder, DDS.)

[10]. In most cases, an initial apical instrumentation with hand instruments


to a size of #15 K-les is necessary and very important. Widening the apical
portion seems to reduce the risk of fracture in constricted, narrow canals
[10,13]. In special cases with complex anatomic structures, in which it is
likely that the use of rotary instrumentation will result in failure, continuing
the shaping procedure by hand instrumentation is the method of choice. In
all other situations, the shaping procedure with ProTaper instruments is
continued. S1 is moved carefully to working length in a brushing technique.
If this goal cannot be achieved or can be achieved only by forcing the
instrument, there are several possibilities that can prevent the le from
moving to apical areas:
1. The utes are covered with debris and dentin chips. The ProTaper
system usually works very eciently and reliably. Eciency decreases
rapidly when the utes of the instrument are blocked with debris.
Cleaning the instrument thoroughly, irrigating the canal, conrming
patency, and repeating the last step usually solves these problems.
2. The coronal aspect of the root canal has not been widened enough,
which occurs most often in long canals. In this case, SX should be used

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Fig. 24. The lower molar was shaped for three-dimensional obturation of the root canals.
(Courtesy of Thomas Clauder, DDS.)

in a more eective way or, as an alternative in very long canals, Gates


Glidden drills can help to widen the coronal and middle portion of the
canal to prevent following les from blocking in these areas.
3. The canal is obstructed in apical areas. Blockage of a rotating
instrument in the apical tight canal leads to extreme torsional loads
on the instrument and high risk of separation. The fact that a canal is
very tight or calcied can be detected by scouting the apical portion of
the canal and establishing working length. The canal should be
instrumented by hand to an appropriate size to reduce the torsional
load on the instrument.
4. The canal is blocked by dentin chips or pulp tissue in the apical portion.
A viscous chelator (EDTA solution) should be irrigated into the canal,
patency should be established with an adequate K-le, and the instrumentation should be repeated with smaller les.
After successful insertion of S1, S2 is used in one or two strokes to
working length in the same manner as described previously (Fig. 15). The
coronal two thirds of the root canal now should be shaped ideally. Apical

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105

Fig. 25. Anatomic variations, like this premolar with three roots, can be introduced with the
system. (Courtesy of Thomas Clauder, DDS.)

preparation is done with the nishing les. For apical gauging and shaping
the technique preferred by Dr. Cliord Ruddle is as follows [12].
The last instrument reaching working length is S2, which has a diameter
of 0.20 mm at the instrument tip and a taper of 4%. F1, which has the same
diameter at the instrument tip, can be worked to working length. Due to the
design of the le, a uniform taper of 7% is produced in the apical portion of
the root canal. The apical diameter of the root canal is gauged with a #20
K-le. The instrument is inserted passively into the canal to working length,
tapping on the head of the instrument to prevent cutting action. If the le
binds in the apical region, the preparation is nished. If the le is loose in the
canal, F2 is inserted to working length. Apical gauging should be repeated
now with a #25 K-le. During this procedure, attention is given to maintain
working length. Does the #25 K-le bind at working length preparation of
the root canal is nished, if the le is loose in the canal, F3 should be used to
working length. Apical gauging should be repeated now with a #30 K-le
(Fig. 16). Does the #30 K-le bind at working length preparation of the root
canal is nished, if the le is loose in the canal a dierent technique should
be chosen to nish apical preparation. With the second use of S1, all

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Fig. 26. The micro-CT evaluation demonstrates the canal anatomy of an upper molar before
instrumentation. (From Peters OA, Peters CI, Schoneberger K, Barbakov F. ProTaper rotary
root canal preparation: eects of canal anatomy on nal shape analyzed by microCT. Int
Endod J 2003;36:87; with permission.)

instruments are inserted to working length. ProTaper instruments provide


a continuous tapered preparation of the root canal, without signicant
transportation of the original position. The ProTaper les engage specic
sections of the root canal system, as the instrument geometry and design
allows. This can be demonstrated very easily, inspecting the instruments for
debris remnants immediately after use. The order of instrumentation and
the varying areas of use for each ProTaper le are shown in Fig. 17. During
the complete shaping procedure, focus also should be given to maintaining
an accurate, precise, and eective antibacterial protocol. After each
instrument irrigation, establishing patency and reirrigation is of extreme
importance to achieve perfect cleaning and shaping objectives.
In cases of severe curvatures, rotational speed of the instruments could be
reduced to a minimum of 150 rotations per minute [14,15] (Fig. 18). In
addition, the lifespan of an instrument is directly proportional to a specic
number of rotary cycles [16]. In cases of pronounced and acute curvatures
[17] with a small radius (Fig. 19), the use of ProTaper les in a hand le
manner is helpful, especially because there are new useful handles available
(Dentsply/Maillefer). The les can be used safely in a watch-winding
motion. Cutting eciency can be improved in a turning motion. ProTaper

T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87111

107

Fig. 27. The micro-CT evaluation demonstrates the canal anatomy of an upper molar after
cleaning and shaping procedures with ProTaper les. (From Peters OA, Peters CI, Schoneberger
K, Barbakov F. ProTaper rotary root canal preparation: eects of canal anatomy on nal shape
analyzed by microCT. Int Endod J 2003;36:87; with permission.)

instruments can be helpful in retreatment cases; the nishing les are


especially useful in the careful removal of gutta percha. For reshaping the
canal anatomy after establishing patency, the instruments can be used in the
previous described sequence, if pretreatment did not result in far greater
apical diameters (Figs. 20 and 21).

Summary
Root canal instrumentation should provide a tapered, adequate canal
shape to allow for eective irrigation and obturation [18]. This can be
accomplished thoroughly with the ProTaper NiTi system (Figs. 22 and 23).
The well-planned le design allows for an ideally prepared root canal of easy
or dicult shape (Figs. 24 and 25). The nish of the root canal instrumentation allows for a predictable obturation of the root canal system,
independent of technique chosen. ProTaper instruments adequately open
canals 5 mm from their apices, with sizes varying from 0.65 mm to 0.79 mm.
Spreaders and pluggers with 0.50-mm tips can be used readily during obturation of root canals with such apical preparations [11]. They also can be
used for antibacterial therapy, allowing for a thorough irrigation technique.

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T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87111

Fig. 28. Superimposing pre- and postoperative data demonstrates the shape created with
ProTaper les following canal anatomy. (From Peters OA, Peters CI, Schoneberger K,
Barbakov F. ProTaper rotary root canal preparation: eects of canal anatomy on nal shape
analyzed by microCT. Int Endod J 2003;36:89; with permission.)

After the ProTaper system was introduced, the possibility of more or less
severe canal transportation produced by active cutting action was discussed.
The latest evidence shows that canals can be prepared with the ProTaper
system without major procedural errors (Figs. 2628) [11,19]. Micro-CT
evaluation of shaped canal studies showed that the ProTaper System tends
to transport canals slightly larger than do le systems with a passive cutting
action [11]. Therefore, it is important to immediately remove the instrument
out of the root canal once working length is achieved. A prolonged rotation
of the instrument with an active cutting blade can lead to unnecessary
misshapes in canal anatomy. This tendency can be minimized by achieving
proper coronal shaping and straight-line access (Fig. 29). Straight-line
access helps to minimize transportation during the shaping procedure [11].
Another study [19] has shown no transportation in the middle section of the
tooth and in apical areas, and little transportation in coronal areas toward
furcation areas. A center displacement toward the furcation area also has
been demonstrated with several NiTi systems on the market [19], but
obviously is not as severe as with a standardized instrumentation technique
using stainless steal instruments [3].

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109

Fig. 29. Sections of treated extracted teeth with ProTaper instruments show a centered
preparation allowing for complete obturation.

The ProTaper les generate lower torque scores than do rotary


instruments with a U-le design (radial land). Furthermore, high forces
that are generated in some cases of constricted canals were insucient to
fracture ProTaper instruments [13]. Constricted canals are a major problem
because of the correlation with high torque values. Using a ProTaper le

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T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87111

seems to minimize fracture risk of the instrument [13]. Apical instrumentation with K-les is extremely important in these cases. In addition,
discarding instrumentsafter or during usethat have been used in
calcied canals helps to minimize the fracture risk of the instrument.
Mathematic models have conrmed that in case of similar apical loads,
ProTaper instruments work longer in a super elastic phase than do
instruments with a U-le design, allowing for high performance and less risk
[20]. The system enables a safe of time compared with hand instrumentation
techniques, especially in simple and predictable cases. In more dicult cases,
the advantage lies in the perfect preparation of the root canal.
The operator should decide on the size of the apical instrumentation
according to the preferred treatment concept, the scientic background, and
the special case selected. If the apical regions are to be enlarged wider than
ISO 30 in large canals, it might be best to use a dierent technique to achieve
the treatment goal rather than using the ProTaper system. Recent studies
have shown that the ProTaper system perfectly shapes curved and constricted
canals [11,13,15]. Wide canals were less eciently instrumented, which is
apparent as the design features and sizes available suite less [11]. Combining
ProTaper system with other NiTi systems emphasize the advantages of the
ProTaper system can provide larger apical sizes. This is discussed in the
article on hybridization of le systems elsewhere in this issue.
References
[1] Ruddle CJ. The ProTaper technique. Endod Prac 2002;5:2230.
[2] Peters OA, Schoneberger K, Laib A. Eects of four NiTi preparation techniques on root
canal geometry assessed by micro computed tomography. Int Endod J 2001;34:22130.
[3] Gluskin AH, Brown DC, Buchanan LS. A reconstructed computerized tomographic
comparison of Ni-Ti rotary GT les versus traditional instruments in canals shaped by
novice operators. Int Endod J 2001;34:47684.
[4] Turpin YL, Chagneau F, Bartier O, Cathelineau G, Vulcain JM. Impact of torsional and
bending inertia on root canal instruments. J Endod 2001;27:3336.
[5] Baumann MA. ProTaperEine neue Generation von Ni-Ti-Feilen [ProTapera new
generation of NiTi-les in endodontics]. Endodontie 2001;10(4):35164.
[6] Ruddle CJ. Cleaning and shaping root canal systems. In: Cohen S, Burns RC, editors.
Pathways of the pulp. 8th edition. St. Louis: CV Mosby; 2001. p. 23191.
[7] Yared GM, Bou Dagher FE, Machtou P. Inuence of rotational speed, torque and
operator prociency on ProFile failures. Int Endod J 2001;34:4753.
[8] Yared GM, Bou Dagher FE, Machtou P, Kulkarni GK. Inuence of rotational speed,
torque and operator prociency on failure of greater taper les. Int Endod J 2002;35:712.
[9] Gambarini G. Cyclic fatigue of ProFile instruments after prolonged clinical use. Int
Endod J 2001;34:3869.
[10] Ruddle CJ. The ProTaper endodontic system. Endod Prac 2002;5(1):3444.
[11] Peters OA, Peters CI, Schoneberger K, Barbakov F. ProTaper rotary root canal
preparation: eects of canal anatomy on nal shape analyzed by microCT. Int Endod J
2003;36:8692.
[12] Ruddle CJ. Finishing the apical one-third. Endod Prac 2002;5(3):1524.
[13] Peters OA, Peters CI, Schoneberger K, Barbakov F. ProTaper rotary root canal preparation:
assessment of torque and force in relation to canal anatomy. Int Endod J 2003;36:939.

T. Clauder, M.A. Baumann / Dent Clin N Am 48 (2004) 87111

111

[14] Martin B, Zelada G, Varela P, Bahillo JG, Magan F, Ahn S, et al. Factors inuencing the
fracture of nickel-titanium rotary instruments. Int Endod J 2003;36:2626.
[15] Zelada G, Varela P, Martin B, Bah llo JG, Magan F, Ahn S. The eect of rotational speed
and the curvature of root canals on the breakage of rotary endodontic instruments. J Endod
2002;28:5402.
[16] Yared GM, Bou Dagher FE, Machtou P. Cyclic fatigue of ProFile rotary instruments after
simulated clinical use. Int Endod J 1999;32:1159.
[17] Pruett JP, Clement DJ, Carnes DL. Cyclic fatigue testing of nickel-titanium endodontic
instruments. J Endod 1997;23:7785.
[18] Schilder H, Yee FS. Canal debridement and desinfection. In: Cohen S, Burns RC, editors.
Pathways of the pulp. 3rd edition. St. Louis: CV Mosby; 1984. p. 175.
[19] Bergmanns L, Van Cleynenbreugel J, Beullens M, Wevers M, Van Meerbeeek B,
Lambrechts P. Progressive versus constant tapered shaft design using NiTi rotary
instruments. Int Endod J 2003;36:28895.
[20] Berutti E, Chiandussi G, Bavaglio I, Ibba A. Comparative analysis of torsional and
bending stresses in two mathematical models of nickel-titanium rotary instruments:
ProTaper versus Prole. J Endod 2003;29:159.

Dent Clin N Am 48 (2004) 113135

The LightSpeed System


Fred Barbakow, BDS, HdipDent, MSc (Med)
Department of Preventive Dentistry, Periodontology and Cariology, School of Dentistry,
University of Zurich, Plattenstrasse 11 CH-8028, Zurich, Switzerland

Successful endodontic therapy calls for optimized chemomechanical


preparation of root canals, disinfection where required, oburation, and
placement of a leakage-free coronal restoration. Traditionally, root canals
are prepared using stainless-steel hand les and reamers. Until approximately 10 years ago, 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]. Specications and
tolerances for hand les currently comply with American Dental Association Specication No. 28 (Council of Dental Materials and Devices, 1976)
and obtained international recognition (International Standards Organization [ISO] status) in 1981 [1]. Progress in le development stagnated
somewhat until the mid-1980s when the balanced force technique and its
associated les were described [2]. Changes in canal preparation evolved
rapidly when two innovative concepts developed independently of each
other during the late 1980s. One was the use of nickel-titanium to
manufacture hand instruments and the second was the development of an
innovative engine-driven instrument, the Canal Master U (Brasseler,
Savannah, Georgia) [3,4]. Subsequently, engine-driven endodontic instruments with this innovative design were manufactured from nickel-titanium
and were marketed as LightSpeed instruments (LightSpeed Endodontics,
San Antonio, Texas).

Design of lightspeed instruments


LightSpeed instruments are quite unique; thus, it is important to describe
the innovative features that make up the instrument. The unique features
include their sizes; short cutting heads; and long, noncutting, taperless shafts
(Fig. 1).
E-mail address: fred.barbakow@zzmk.unizh.ch
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.10.003

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F. Barbakow / Dent Clin N Am 48 (2004) 113135

Fig. 1. Overview of a LightSpeed instrument (left) with its short cutting head and thin
noncutting taperless shaft compared with a K-FlexoFile (Dentsply-Maillefer, Ballaigues,
Switzerland) (right) with its 16-mm-long cutting surface.

Sizes
A set of LightSpeed instruments totals 26 and encompasses sizes 20 to
140; the instruments are marketed in lengths of 21 mm, 25 mm, and 31 mm.
In addition to the color-coded full ISO sizes, LightSpeed instruments also
have half-sizes, placing sizes 22.5, 27.5, 32.5, respectively, between sizes 20
and 25, between sizes 25 and 30, and between sizes 30 and 35. The last two
half-sizes are sizes 57.5, and 65, which t between sizes 55 and 60 and
between sizes 60 and 70, respectively. The half-sizes are color-coded exactly
as the previous size, but also have white or black markings or engraved rings
on the instruments handles. These markings or rings are important, because
it is impossible to identify the full size from its corresponding half-size by
color alone.
Cutting heads
LightSpeed cutting heads are designed to operate in a continuous
clockwise rotation and have three radial lands and three U-shaped spiral

F. Barbakow / Dent Clin N Am 48 (2004) 113135

115

grooves between the radial lands. Although cutting surfaces of most enginedriven instruments are 16 mm long, the smallest (size 20) and largest (size
140) LightSpeed cutting heads are 0.25 mm and 2.25 mm long, respectively.
In addition, LightSpeed is the only rotary system whose cutting heads have
three dierent geometric shapes (Fig. 2). The rst ve LightSpeed
instruments (sizes 20 through 30) have short, noncutting pilot tips and
a 75-degree cutting angle. Instrument size 32.5 is a transition instrument
with a slightly longer noncutting pilot tip and a 33-degree cutting angle. All
other instruments (sizes 35 through 140) have longer and more slender
noncutting pilot tips than do the transitional instrument and a 21-degree
cutting angle. The major dierences between LightSpeed instruments and
conventional stainless steel and nickel-titanium hand les are summarized
in Table 1. Cutting heads of all LightSpeed instruments terminate in
noncutting pilot tips (Fig. 3). The spiral grooves help to transport debris
coronally, whereas the radial lands and noncutting pilot tips help rotating
LightSpeed instruments to remain better centered in canals (Fig. 4).
Thin shafts
LightSpeed is the only rotary system whose instruments have thin,
taperless, noncutting shafts. This design maximizes the exibility of nickeltitanium and enables instruments to negotiate primary, secondary, and
tertiary curves in both the bucco-lingual and mesio-distal planes. Fig. 5
illustrates a cross-section, 1.5 mm from the root apex, showing dierent
parts of two cutting heads in two canals with dierent working lengths. In
one canal, the noncutting pilot tip is sectioned, whereas in the other, the
radial lands and spiral grooves are sectioned.

Fig. 2. SEM photomicrograph of three LightSpeed cutting heads showing dierences between
sizes 20 (top), 32.5 (right), and 40 (left) and the radial lands and spiral grooves (original
magnication 40).

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F. Barbakow / Dent Clin N Am 48 (2004) 113135

Table 1
Dierences between LightSpeed instruments and conventional stainless-steel endodontic les

Metal/alloy
Shaft diameter
Length of cutting head (mm)
Tip angles
Noncutting pilot tip
Tip design constant
Intermediate sizes
Tolerance
Smallest size
Largest size
a
b
c

LightSpeed instruments

Conventional hand les

Nickel-titanium
0.16 to 0.51 mm
0.25 (20) to 2.25 (140)
Varies; 21, 33, and 75 degrees
Yes
No
Yes
0.005 mmc
20
140

Stainless steel
Increases linearly
16 size
Similar for all les
Noa
Yes
Nob
0.02 mm
08
140

Some les have a batt geometry.


Golden Mediums (Dentsply Maillefer, Ballaigues, Switzerland) have intermediate sizes.
Steve Senia, DDS, San Antonio, Texas, personal communication, July 2003.

Shanks and handles


The thin, taperless nickel-titanium shaft enlarges at one end to become
the shank, which in turn inserts into the aluminum handle. The shank is
marked with rings that indicate distances from the instruments tip. For the
21-mm and 25-mm instruments, the junction of the shaft and shank is 18
mm from the tip, and for the 31-mm instrument, the distance is 22 mm.
Although the 21-mm instruments have only one ring on the shank, which is
20 mm from the tip, the 25-mm instruments have three rings indicating
distances of 20 mm, 22 mm, and 24 mm from the tip. In contrast, the 31-mm
instruments have four rings on the shank, indicating distances of 24 mm, 26
mm, 28 mm, and 30 mm from the tip. Junctions between shanks and colorcoded handles are 21 mm, 25 mm, and 31 mm from the tips for the 21-mm,
25-mm, and 31-mm long instruments, respectively. The markings on the

Fig. 3. SEM photomicrograph of a LightSpeed cutting head showing the noncutting pilot tip,
radial lands, spiral grooves, and part of the taperless shaft in an unusual perspective (original
magnication 200).

F. Barbakow / Dent Clin N Am 48 (2004) 113135

117

Fig. 4. Front and back of a LightSpeed cutting head showing dentin debris lling spaces
between radial lands.

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, LightSpeed instruments should rotate at a constant speed
between 1500 and 2000 revolutions per minute (rpm) without exceeding
2000 rpm. Foot pedals on dental units should be adjusted to maintain the
constant speed, although cordless handpieces are recommended because of
their low cost, constant speed, constant torque, and ease of use. LightSpeed
instruments operate optimally at high rpm in low-torque motors; the constant rpm is important because nickel-titanium does not tolerate repeated
changes in torque. Instruments should already be rotating as they enter the
canal, continue rotating while cutting canal walls, and stopped only when
the instrument is removed from the canal orice.

Fig. 5. Root apices of a maxillary rst premolar with the LightSpeed MAR instruments xed in
situ and cross-sectioned 1.5 mm from the tip showing the noncutting pilot tip and the cutting
blades in the two canals. Working length is dierent in the two canals (original magnication
64, scale 0.5 mm).

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F. Barbakow / Dent Clin N Am 48 (2004) 113135

LightSpeed instruments require a straight-line access to the mid-root


area. Consequently, cavity walls should be shaped so that they guide the
rotating instruments unhindered to the mid-root area. This may require
rasping coronal canal overhangs using size 15, 20, and 25 Hedstrom les
(Dentsply Maillefer, Ballaigues, Switzerland). Because the smallest LightSpeed instrument is a size 20, working lengths should rst be reached with
a loose-tting, size 15 hand le. In very narrow canals it may be necessary to
rst reach the working length with size 08 or size 10 K-Files (Dentsply
Maillefer), preferably using the Balanced Force technique [2]. Copious
irrigation is important and it is advisable to maintain a reservoir of the
irrigant in the pulp chamber. Irrigants help to remove debris that rapidly
collects within the cutting utes, thus maintaining the instruments cutting
eciency. A proven concept is to irrigate alternately with sodium hypochlorite and a liquid ethylenediaminetetraacetic acid, using the latter when
LightSpeed is working in the canal and as the nal ush.
With LightSpeed, always use progressively larger instruments in the
correct sequence from small to large, never skipping a size to gain time.
However, one way to gain time is to use two or more handpieces. Two
handpieces expedite instrument changeovers because although the clinician
uses one handpiece, the chairside assistant can t the next LightSpeed
instrument into the second handpiece and set the length, if rubber stops are
used. Once a LightSpeed instrument has reached its desired length, do not
linger at that point and immediately withdraw the rotating instrument from
the canal. No further shaping can occur and lingering at a point only
subjects the instrument to additional unnecessary metal fatigue.

Details of the lightspeed technique


Manufacturers of any rotary instruments modify their techniques from
time to time, and clinicians frequently employ their own variations as well.
Such modications or evolutionary changes have occurred with LightSpeed
as well. These changes indicate an increased condence with the techniques;
being able to modify the principles; adapting newer techniques to existing
ones; and, most importantly, because the anatomy of root canals vary so
widely. For the sake of completion, three methods of using LightSpeed instruments are described. The rst is the Zurich LightSpeed technique [57], the
second is the manufacturers recommended LightSpeed technique [8,9], and
the third is the manufacturers recommended hybrid technique. Publications
have already described how dierent tapered rotary systems can be combined
[10] and LightSpeed can readily be combined with other tapered systems.
Zurich LightSpeed technique
Three special instruments should be singled out while using the Zurich
LightSpeed technique. These are the initial apical rotary (IAR), the

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master apical rotary (MAR), and the nal rotary (FR) [7]. The IAR is
dened as the rst LightSpeed instrument, which begins to cut canal walls at
the working length, whereas the MAR is the last instrument to form the
apical preparation. The MAR may be 6 to 12 LightSpeed sizes larger than
the IAR. The FR is the last step-back instrument and completes the stepback procedure.
The Zurich LightSpeed technique is divided into four steps. Step 1
constitutes the access and coronal prearing, step 2 determines working
length and the IAR, step 3 determines the MAR, and step 4 completes the
step-back and recapitulation.
Step 1: Access and coronal prearing
After the canal orices are located, their diameters are enlarged in a stepdown or crown-down procedure using Gates-Glidden burs (GGBs;
Dentsply Maillefer), progressing from large to small sizes [11,12]. In shorter
canals, two GGBs may suce; in longer canals, three or four GGBs may
be indicated. Each GGB advances only 1 mm to 1.5 mm into the canal,
enlarging no more than the coronal 4 mm to 6 mm. It is important to follow
the roots long axis and oval canals can be milled readily with the GGBs.
The step-down procedure or prearing removes signicant amounts of
necrotic tissue and microorganisms from the canal coronally.
Step 2: Determine working length and IAR
After prearing, the working lengths are determined for each canal using
at least size 15 stainless steel K-Files; this is veried radiographically or
electronically. LightSpeed instruments are used from this point on,
beginning with size 20; the aim is to reach the working length. The rst
few LightSpeed instruments used may not ream the canal walls because the
canals are too large; these instruments are termed nonbinding instruments. Nevertheless, always begin with size 20, sequentially progressing to
larger sizes without skipping a single size. Nonbinding instruments advance
in steps of 1 mm to 2 mm to the working length with slow, controlled
movements. Eventually, one LightSpeed instrument will start to cut the
canal walls at working length; this instrument is designated the IAR.
Step 3: Determine MAR
All LightSpeed instruments used after the IAR are called binding
instruments. They are used with controlled forward (1 mm to 2 mm) and
backward (2 mm to 4 mm) pecking movements. The forward motion
reams the canal, whereas the backward motion tends to clean the cutting
head as it retreats into fresh irrigant. These instruments also are used
sequentially from smaller to larger sizes, each advancing with the pecking
movements. The diameter of the apical preparation increases with each
instrument that reaches working length. The last instrument used to form

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the apical preparation is the MAR. The MAR may be 6 to 12 LightSpeed


instruments larger than the IAR.
The exact position of the apical preparation in relation to the
radiographic apex depends on the clinicians own philosophy and will vary
from dentist to dentist. Likewise, the diameter of the nal apical preparation
also is controversial because it has been virtually ignored. For this reason, it
has been called the forgotten dimension [9]. To ensure that the apical
preparation has cleaned the canal, the preparations nal size must be larger
than the canals preinstrumentation diameter. A review of the literature
suggests the average sizes for MARs (Table 2) [9].
The size of the MAR can be modied and depends on several factors such
as the degree and angle of curvature, presence of secondary or tertiary
curves in the canal, thinner or wider root apices, and amount of canal
obliteration. 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.
In contrast, a broad apex calls for a larger MAR.
Step 4: Step-back and recapitulation
LightSpeed instruments are stepped-back after selecting the MAR. The
working length for the rst step-back instrument is 1 mm shorter than the
canals working length, and each subsequent step-back instrument is 1 mm
shorter than the previous instrument. The number of step-back instruments
will vary from canal to canal. The last step-back instrument is termed the
FR and runs into the step-down or coronal prearing previously prepared.
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

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Finally, all canals are recapitulated once with using their respective MARs
to working length. Figs. 6 through 9 detail four molars that were
endodontically treated by general practitioners using the Zurich LightSpeed
technique.
The Zurich LightSpeed technique can be combined readily with currently
marketed tapered rotary systems. This procedure calls for .04 or .06 tapered
system to be used according to the manufacturers instructions, but only
until the size 20 instrument completes the crown-down mode. From this

Fig. 6. (A) Working length radiograph of a mandibular second molar scheduled for LightSpeed
preparation using the Zurich technique (February 11, 1997). Note the apical periodontitis on
the mesial and distal root apices (case supplied by Dr. A. Bindl). (B) Final ll radiograph
(lateral condensation) of the mandibular second molar (Fig. 6A) prepared with LightSpeed
instruments (May 27, 1997). MAR in all canals was size 50. Both apical radiolucencies are
resolving (case supplied by Dr. A. Bindl). (C) Thirty-month follow-up radiograph of the
mandibular second molar shown in Fig. 6A with a Cerec (Sirona, Bensheim, Germany)
restoration and healed apical areas (January 28, 2002; case supplied by Dr. A. Bindl).

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Fig. 6 (continued )

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

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123

Fig. 7. (A) Radiograph of the nal ll (lateral condensation) of four canals in a maxillary rst
molar prepared with LightSpeed instruments using the Zurich technique (December 12,
1996). MAR in the four canals was size 47.5 (case supplied by Dr. A. Bindl). (B) Five-year
follow-up radiograph of the maxillary rst molar shown in Fig. 7A (February 24, 2003). MAR
in all four canals was size 47.5 (case supplied by Dr. A. Bindl).

the above example, if size 25 reaches working length but size 27.5 does not,
then size 27.5 is called the First LightSpeed Size to Bind (FLSB). The FLSB
is placed in the handpiece to begin rotary instrumentation.
Step 2: Determine the apical preparation size
Start instrumenting with the FLSB using a slow, continuous movement,
advancing cautiously until it engages the canal walls. At this point,
immediately stop advancing, pause for a fraction of a second, and then
progress apically with an advance and withdrawal motion (pecking). This
pecking movement translates into a downward cut of the dentin followed

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Fig. 8. (A) Working length radiograph of a mandibular second molar scheduled for
preparation with LightSpeed instruments using the Zurich technique (November 1994).
Note the endo-perio lesion adjacent to the distal root (case supplied by Dr. J. Zafran). (B)
Eighteen-month follow-up radiograph of the mandibular second molar shown in Fig. 8A (April
1996) obturated with ThermaFil. MAR in the two mesial canals and one distal canal were sizes
42.5 and 50, respectively. Note the healed endo-perio lesion adjacent to the distal root (case
supplied by Dr. J. Zafran).

by a slight withdrawal of about 1 to 3 mm. Count the number of pecks it


takes the FLSB to reach working length, repeating the counting of pecks
with each sequentially larger instrument. As the canal is cut rounder, the
cutting head works harder because it is removing more dentin. The extra
cutting eort requires more pecks to advance the instrument from when it
starts cutting until it reaches working length.
After determining the FLSB, the appropriate size of the apical
preparation to achieve the signicant goal of apical cleaning is determined.
The instrument that takes at least 12 pecks to reach working length is the

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125

Fig. 9. (A) Final ll radiograph (ThermaFil) of a mandibular second molar prepared with
LightSpeed instruments using the Zurich technique (November 1994). MAR in the two
mesial canals and one distal canal were sizes 42.5 and 50, respectively (case supplied by Dr. J.
Zafran). (B) Fifteen-month follow-up radiograph of the mandibular second molar shown in
Fig. 9A (February 1996; case supplied by Dr. J. Zafran).

MAR. This is called the 12 pecks rule. Canals with naturally large or
small sizes will have larger- or smaller-sized MARs, respectively. The size of
the MAR depends on the preinstrumentation canal size, which varies from
tooth to tooth. There is no such thing as a given canal size for each tooth in
the mouth.
Step 3: Complete apical instrumentation
After determining the MAR size with the 12 pecks rule, complete the
apical preparation by using the very next LightSpeed size that is 4 mm
shorter than the working length. This enables the 5-mm long SimpliFill GP

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

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127

A. If the size 35 instrument reaches working length without binding,


continue gauging with sequentially larger LightSpeed instruments
until one binds before the working length (as explained previously, this
instrument is called the FLSB). Then proceed to step 2.
B. However, if the size 35 instrument does not reach working length but
binds 3 mm (or less) short of the working length, then it also is called
the FLSB. Proceed to step 2.
C. If the size 35 LightSpeed instrument binds more than 3 mm short of
the working length, it means that the apical part of the canal is not
ready to be mechanically prepared with LightSpeed instruments.
Reconrm that the tapered preparation was performed correctly. If
conrmed to be correct and the size 35 gauging instrument still does
not bind within 3 mm of working length, then le the canal with
K-les until a size 35 LightSpeed instrument reaches working length.
Proceed to step 2.
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. The apical preparation is complete when the canal is
instrumented to the MAR using the 12 pecks rule.

Discussion
This article discusses three ways to use LightSpeed instruments. Purists
may contend that the manufacturers recommended technique always should
be followed to the letter. Although some clinicians may do just that, others
modify the methods that they have learned at courses on LightSpeed or other
nickel-titanium rotary techniques. Consequently, two of the three techniques
in this article describe using LightSpeed instruments alone and one describes
the combined use of LightSpeed with tapered rotary instruments. Although
using two rotary techniques has advantages, some clinicians complain about
combining two systems and the related increased costs. Nevertheless, the
three techniques are described to give experienced and nonexperienced users
pointers on how LightSpeed instruments may be used.
Generally, LightSpeed instruments enable larger apical preparations
because their design maximizes the exibility of nickel-titanium more so than
do other rotary instruments currently available, particularly for the larger
sizes. Independent studies performed since 1995 [1421] indicate that LightSpeed instruments produce better-centered apical preparations compared
with other les or instruments. For example, apical preparations in mesial
canals of mandibular molars produced little or no apical transportation
when prepared by LightSpeed instruments [14], even when canals were

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F. Barbakow / Dent Clin N Am 48 (2004) 113135

prepared using size 50 LightSpeed instruments [17]. Although apical


preparations can be made to larger sizes, coronal thirds are not overinstrumented because of the unique design of LightSpeed instruments. On
the other hand, microcomputer tomography [22] showed that up to 40% of
root canal walls remained uninstrumented when shaped by dierent rotary
techniques or manually [23].
The logical question is are larger apical preparations necessary? Recent
studies [2427] indicate that larger apical preparations removed more
infected tissue and bacteria. Furthermore, larger apical preparations create
more space for larger amounts of irrigants to ensure a more eective
disinfection [28]. Detailed anatomy of apical constrictions [29] and mean
diameters of root canals near the apical foramina [3033] suggest that larger
preparations are necessary to optimize the cleaning procedure. To highlight
this point, 95% of molar mesial canals require shaping to at least a size 60 to
adequately instrument the apical 1 mm [32].
To summarize, it is well established that bacteria in root canals are
endodontists main problems and if larger apical preparations reduce
bacterial counts, then it is logical to conclude that larger apical preparations
may yield better outcomes. However, despite an electronic scan of the
literature, no publications were found linking better clinical outcomes to
larger-sized apical preparations. Nevertheless, if the chemomechanical
removal of microorganisms is the goal in endodontics, an apical preparation
larger than the uninstrumented canal size must be the aim of any root canal
preparation.
Instrument maintenance and replacement
Concepts must be in place so that chairside assistants know how
frequently rotary instruments have been used clinically. LightSpeed instruments are too expensive to be used only once, but cyclic and torsional
fatigue may cause instruments to fracture if they are used too frequently.
Consequently, the manufacturer recommends using the smaller LightSpeed
sizes (2047.5) for up to 8 cases and the larger sizes (50 and above) for up to
16 cases. They suggest that each tooth with normal canal curvatures,
including molars, be considered a case (Steve Senia, DDS, San Antonio,
Texas, personal communication, July 2003). Instruments should be replaced
after a single use when the degrees of curvature are excessive or abrupt
(short radius) curvatures are present.
After usage, 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 utes. The instruments then can be
sorted, placed in the special LightSpeed Organizer (LightSpeed Endodontics), and sterilized in the usual manner. Wear of LightSpeed cutting heads
includes microfractures, disruption, metal strips, and pitting or fretting
(Figs. 10, 11); minor imperfections also were found on new instruments

F. Barbakow / Dent Clin N Am 48 (2004) 113135

129

Fig. 10. Photomicrograph (original magnication 215) showing metal strip on the noncutting
pilot tip of a size 37.5 LightSpeed instrument used clinically in 20 canals. (Modied from
Marending M, Lutz F, Barbakow F. Scanning electron microscope appearance of Lightspeed
instruments used clinically: a pilot study. Int Endod J 1998;31(1):60; with permission.)

Fig. 11. Photomicrograph (original magnication 90) of a disrupted edge and metal ash of
radial lands of a size 50 LightSpeed instrument used clinically in 20 canals. (Modied from
Marending M, Lutz F, Barbakow F. Scanning electron microscope appearance of Lightspeed
instruments used clinically: a pilot study. Int Endod J 1998;31(1):60; with permission.)

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F. Barbakow / Dent Clin N Am 48 (2004) 113135

[34,35]. It would be interesting to compare the wear of LightSpeed


instruments to the wear of other nickel-titanium rotary instruments. Minor
imperfections in unused LightSpeed instruments show how dicult it is to
machine such delicate nickel-titanium instruments.
Instrument fracture
Any rotary instrument can fracture, particularly in curved canals when
the manufacturers basic guidelines are ignored. When used properly,
LightSpeed instruments are not prone to fracture but when they do,
fractures may occur at two sites. One is at the shaftshank junction and is
due to excessive angulation of the instrument in the canal orice combined
with poor access or unintended tipping of the handpiece by the clinician
(Fig. 12A, B). Such fractured instruments are removed readily from the root
canals. 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, which accelerates metal fatigue. Such fractured
segments are more dicult to remove (Fig. 13AC). They may be bypassed,
or left in situ and integrated in the oburation. The latter is indicated when
larger instruments are involved and the greater part of the canal has been
cleaned and well irrigated.
Explain any mishap to the patient, informing him or her of the pros and
cons involved in any subsequent therapy. Also tell the patient how
important regular follow-ups are to determine the treatments outcome.
Instrument fracture is a real concern for clinicians, but practicing the
technique diligently and being aware of the important dos and donts
pertinent to the LightSpeed technique can signicantly reduce the incidence
of fracture. Box 1 summarizes the more important dos and donts pertinent
to the innovative LightSpeed technique. LightSpeed instruments are fascinating, innovative, and maximize the exibility of nickel-titanium. Just as
with any new technique, the LightSpeed methods should be mastered before
using them on patients, beginning with simpler canals and then progressing
to more challenging cases.

Summary
LightSpeed instruments, with their short cutting heads, noncutting pilot
tips, and long thin taperless shafts, are unique in their design. The
instruments maximize the exibility of nickel-titanium, particularly for the
larger sizes. Consequently, they enable larger apical preparations without
overpreparing the coronal canal thirds. By so doing, better mechanical
removal of necrotic debris and microorganisms may be possible. With larger
canal spaces, more disinfecting irrigants can reach the apical areas and may
ensure a better disinfection.

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131

Fig. 12. (A) Radiograph showing a fracture in the shaft-shank area of a LightSpeed
instrument in the disto-buccal canal of a maxillary rst molar (case supplied by Dr. N. Gabutti).
(B) Final ll radiograph of the tooth shown in Fig. 12A following removal of the fractured
LightSpeed segment from the disto-buccal canal (case supplied by Dr. N. Gabutti).

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F. Barbakow / Dent Clin N Am 48 (2004) 113135

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Box 1. Summary of dos and donts when using LightSpeed


instruments
Dos
1. Use a light touch at all times
for all sizes
2. Always irrigate canals
before using LightSpeed
instruments
3. Maintain a reservoir of
irrigant in the pulp chamber
4. Control the forward and
backward motions when
carrying out the pecking
5. Reduce the feed distance
when resistance is felt
6. Maintain a constant speed
7. Ensure that the instrument
continuously rotates
while in the canals
8. Never skip an instrument
size to try and gain time
9. Always concentrate when
using LightSpeed
instruments
10. Replace instruments at
regular intervals

Donts
1. Dont force LightSpeed
instruments
2. Dont use LightSpeed
instruments in
dry canals
3. Dont exceed a speed
of 2000 rpm
4. Dont linger at a point when
the working length has
been reached
5. Dont vary the speed while
instruments are rotating in
the canal
6. Dont use LightSpeed
without rubber dam
7. Dont overuse LightSpeed
instruments

Acknowledgments
The author thanks many people who helped compile this manuscript
including Andi Bindl, Nick Gabutti, Peter Velvart, and Jakob Zafran
for allowing the author to present their LightSpeed cases and Liselotte
Brandenberger, Beatrice Sener, and Anna-Lise Teuscher for preparing the
photographic material. A nal word of thanks goes to Syngcuk Kim and
b
Fig. 13. (A) Radiograph showing a fractured LightSpeed instrument in a mesial canal of
a mandibular second molar (case supplied by Dr. P. Velvart). (B) View of the fractured surface
of a LightSpeed shaft seen through an operating microscope and the retrieved instrument after
removal using ultrasonics (case supplied by Dr. P. Velvart). (C) Radiograph conrming
retrieval of the fractured LightSpeed segment shown in Fig. 13A (case supplied by Dr. P.
Velvart). (D) Final ll radiograph after retrieving the fractured segment shown in Fig. 13A (case
supplied by Dr. P. Velvart).

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F. Barbakow / Dent Clin N Am 48 (2004) 113135

John Vassallo for their patience and understanding. All these names prove
yet again that no man is an island to himself.
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[27] Rollison S, Barnett F, Stevens RH. Ecacy of bacterial removal from instrumented root
canals in vitro related to instrumentation technique and size. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2002;94(3):36671.
[28] Peters OA, Barbakow F. Eects of irrigation on debris and smear layer on canal walls
prepared by two rotary techniques: a scanning electron microscopic study. J Endod 2000;
26(1):610.
[29] Dummer PMH, McGinn JH, Rees DG. The position and topography of the apical canal
constriction and apical foramen. Int Endod J 1984;17(4):1928.
[30] Kerekes K, Tronstadt L. Morphometric observations on root canals of human anterior
teeth. J Endod 1977;3(1):249.
[31] Kerekes K, Tronstadt L. Morphometric observations on root canals of human premolars.
J Endod 1977;3(2):749.
[32] Kerekes K, Tronstadt L. Morphometric observations on the root canals of human molars.
J Endod 1977;3(3):1148.
[33] Gani O, Visvisian C. Apical canal diameter in the rst upper molar at various ages. J Endod
1999;25(10):68991.
[34] Marending M, Lutz F, Barbakow F. Scanning electron microscope appearance of
LightSpeed instruments used clinically: a pilot study. Int Endod J 1998;31(1):5762.
[35] Eggert C, Peters O, Barbakow F. Wear of nickel-titanium LightSpeed instruments
evaluated by scanning electron microscope. J Endod 1999;25(7):4947.

Dent Clin N Am 48 (2004) 137157

The K3 rotary nickeltitanium le system


Richard E. Mounce, DDS
Private Practice, 511 Southwest 10th Avenue, No. 1108, Portland, OR 97205, USA

The K3 rotary nickeltitanium le system (SybronEndo, Orange,


California) was introduced initially in North America in January 2002
(Fig. 1). The K3 system was designed by Dr. John McSpadden (Lookout
Mountain, Georgia). The K3 has universal applicability across a wide range
of clinical indications and includes the following features:
1. K3 canal shaping les with a xed taper of 0.02, 0.04, or 0.06. (The 0.02
tapered K3 les are available in tip sizes 15 to 45 and in 21-, 25-, and 30mm lengths; the 0.04 and 0.06 tapered K3 les are available in tip sizes
15 to 60 and in 21-, 25-, and 30-mm lengths) (Fig. 2).
2. A slightly positive rake angle (Fig. 3). A positive rake (cutting) angle
provides a more eective cutting surface than a negative one. U-shaped
rotary instruments possess a negative rake angle.
3. A variable core diameter (Fig. 4). This feature enhances exibility over
the entire cutting length.
4. A series of three radial lands with a relief behind two of the three lands
(Fig. 5). This feature reduces friction on the canal wall.
5. Asymmetrically placed radial lands and unequal land widths, ute
widths, and ute depths (Fig. 6). Asymmetrical utes allow the K3 to
provide superior canal tracking, virtually eliminate transportation, aid
in preventing the le from screwing into the canal, and add peripheral
strength. The proportion of the core diameter to the outside diameter is
greatest at the tip where strength is most needed. The proportion then
decreases uniformly as the uting moves up the taper, resulting in
greater ute depth and increased exibility while maintaining strength.
6. An Axxess handle design, which shortens the le handle by
approximately 5 mm without aecting the working length of the le
(Fig. 7).

E-mail address: Lineker@aol.com


0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.11.002

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Fig. 1. The K3 rotary nickeltitanium le system (SybronEndo, Orange, California) was


introduced initially in North America in January 2002.

7. A variable ute pitch (Fig. 8). This feature also helps prevent the
screwing-in eect common with some brands of les and promotes
debris removal.
8. Color coding to distinguish between dierent tip sizes and tapers
(Fig. 9).
9. A safe-ended cutting tip (Fig. 10).
10. K3 body shaper les with an enhanced taper of 0.08, 0.10, and 0.12
that can act as both canal shaping les, orice openers, and deep body

Fig. 2. The availability of K3 canal shaping les with regard to taper, tip size, and length.

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139

Fig. 3. The K3 has a positive rake angle, providing a more eective cutting edge (SybronEndo).

shaping les (these are available in a xed tip size of 25 and in 17-, 21-,
and 25-mm lengths) (Fig. 11). These body shapers have a modied design
relative to the 0.02, 0.04, and 0.06 tapered K3 les. The body shapers
have a shorter taper length (the apical 8 mm, which provides the cutting
function to the le), allowing for a smaller maximum diameter at the
shank and creating a more exible instrument. The uting on the straight
(nontapered) shank is not designed to cut eectively and the straight

Fig. 4. The K3 has a variable core diameter, which increases exibility over the entire cutting
length.

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Fig. 5. (AC) In cross-section, the K3 has a series of three wide radial lands to keep the le
centered, with a relief behind two of the lands. The feature reduces friction on the canal wall and
prevents the le from overengagement.

shank section does not have relieved radial lands. The remaining utes
are parallel so as to increase le exibility and optimize the rate at which
the le can be introduced into the canal. By design, the K3 body shapers
channel debris away from their tips, which can mean somewhat less
required recapitulation, less cutting time, and decreased fracture rates.
Like the original K3 les, the tapered region of the body shapers utes
are relieved at the distal of their radial lands to reduce peripheral surface
contact, enhancing performance. Generally, these les are rotated at 350
rpm. The K3 body shapers have a slightly dierent helix angle relative to
the other K3 sizes and tapers to make them cut more smoothly.

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Fig. 5 (continued )

The authors experience with the K3


In the authors hands, the K3 feels stable and solid. It does not feel as
though the le will fracture at any moment. In essence, the K3 moves
smoothly down the canal with a robust sense of tactile control. The K3
negotiates canals with ease and without undue force.
The K3 has excellent fracture resistance, far better than other
commercially available brands, especially those of variable taper (Fig. 12).

Fig. 6. The K3 (right panel) has asymmetrically placed radial lands of unequal width and
unequal ute widths and depths that aid in preventing the le from screwing into the canal. In
contrast, U-shaped les (left panel) have symmetrical attributes that promote screwing in,
increasing the risk of separation.

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Fig. 7. An Axxess handle design, which shortens the le handle by approximately 5 mm


without aecting the working length of the le.

It also has excellent cutting ability. The le cuts dentin eectively, yet does
not pull itself into the canal apically.
The K3 can be used more than once in all tapers, especially above a tip
size of 25. How many times a le can be used before it is discarded is a matter
of clinical judgment (see the later section on Assumptions for K3 clinical
technique). The K3 will bend out of straight alignment when used beyond
its elastic limit and should be discarded with this occurrence and with
the presence of wear marks. This ability to bend is a unique feature not
possessed by other commercially available brands.
The 17-mm body shapers have the greatest universal applicability. The
25-mm K3 canal shaping instruments are easier to visualize under the
surgical operating microscope due to the Axxess handle. The 25-mm K3 les
are easy to use and visualize even with patients of limited opening and
access.
The K3 instruments are more than adequately exible. Their tactile sense
of rigidity or stiness in hand has no clinical correlation. The 0.02 and

Fig. 8. The K3 has a variable ute pitch to reduce the screwing in eect common with some
brands of rotary nickel titanium les.

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143

Fig. 9. The K3 has simple color-coding to distinguish between dierent tip sizes and tapers.

0.04 tapered K3 les in the smallest tip sizes (1520) make excellent tracking
les as an aid to helping create and/or accentuate a glide path. Specically,
after a glide path has been established to a size 10 K le, for example, the
0.02 and 0.04 size 15 le will generally slide close to true working length and
create eciencies with regard to insertion of subsequent les. Because the
K3 tracks the canal easily, it moves smoothly down the root to accentuate
the initial shapes created by hand in the preparation of the glide path.

Literature
Because of the relatively recent introduction of the K3 into the
marketplace and despite its widespread popularity, there is limited literature
available.
Bergmans and colleagues [1], using microfocus CT, concluded that in
extracted teeth, the ProTaper (Dentsply Tulsa Dental, Tulsa, Oklahoma)
and the K3 were capable of preparing canals with optimum morphological
characteristics in curved canals. In addition, the amount of dentin
removal at all separate horizontal regions was comparable for both groups.
There was no signicant dierence in transportation between the two groups
and with regard to their tendency to straighten the canal.

Fig. 10. A safe-ended cutting tip.

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Fig. 11. K3 body shaper les with enhanced taper of 0.08, 0.10, 0.12 that can act as both
canal shaping les, orice openers, and deep body shaping les (these are available in a xed tip
size of 25 and in 17-, 21-, and 25-mm lengths (SybronEndo).

Shafer and Florek [2] compared K3 to stainless steel K-Flexoles 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. Pre- and postinstrumentation images were recorded and an
assessment with regard to material removal was measured at 20 points
beginning 1 mm from the apex. The authors concluded that the K3 instruments achieved better canal geometry and showed signicantly less canal
transportation than the hand-powered K-Flexoles. During the preparation of 96 canals, 11 K3 instruments fractured.
This studys ndings with regard to le fracture do not match clinical
reality as experienced by the author. In the authors personal experience

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Fig. 12. (A, B) The K3 has excellent fracture resistance. Removal of separated rotary nickel
titanium les is an ultrasonic microscopic procedure as illustrated.

with the K3 in daily clinical practice, the K3, for the most part, is dicult to
fracture and will do so only if used after it has acquired deformations (an
indication for being discarded) or a signicant amount of undue force is
placed on it. It is possible that the performance characteristics of the K3 in
resin bear no resemblance to those in human teeth and that the master
apical rotary size used in the study (size 35) is larger than that most
commonly employed in clinical practice. Also, rotating the les at 250 rpm
may also have contributed to this nding instead of at the recommended 350
rpm.

Assumptions for K3 clinical technique


Use of the K3 embraces the following concepts for enhanced cleansing
and shaping and prevention of le separation. Although many of these
assumptions are also applicable to other rotary le systems, when employed
with the K3, the operator can be assured of optimal K3 performance and
more predictable long-term clinical results.
 Be gentle and deliberate in your motions with the K3. Never put more
force on a K3 le than you would use on a soft lead pencil. Do not force

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a K3 apically that resists movement. Pull back at the rst sign of undue
resistance in the canal. The motion in entering the K3 into the canal
should be slow, gentle, smooth, and deliberate and in approximately 1to 2-mm deeper increments relative to the last instrument.
Frequent irrigation with 5.25% sodium hypochlorite is desirable. An
average molar tooth might optimally require 72 to 144 cc of irrigant
delivered with a close-ended, side-venting needle. The longer the irrigant
is in contact with the canal, the more eective its tissue dissolving
capability, especially in the apical third. EDTA or sodium hypochlorite
(or both) should be in the canal or canals at all times. Failure to do so
(instrumenting dry) can create a plug of apical dentin mud and increase
the risk of transportation or instrument fracture. EDTA should be used
from the start in all vital cases and can emulsify and hold the pulp in
suspension until its removal by way of irrigation. Failure to do so can
create a collagenous mass of pulp that can be pumped irretrievably into
the narrowing cross-sectional diameters of the root canal system, often
with iatrogenic results.
Removal of the smear layer present after instrumentation is desirable.
Rinsing or soaking the canal with liquid EDTA (SmearClear,
SybronEndo) after a nal sodium hypochlorite irrigation is optimal.
SmearClear includes surfactants that reduce surface tension and allow
maximum wetting of the canal walls for greatest ecacy (Fig. 13).
Patency is maintained. Patency refers to the deliberate attempt to keep
the minor constriction of the apical foramen open during instrumentation procedures so as to block the apex with dentin mud, move the canal
from its original position, or change the foramens original size and
shape. Dentin mud includes pulp and dentin debris from instrumentation that can plug the apical foramen and prevent negotiation to the
constriction mentioned previously. Patency is important primarily
because its loss causes signicant debris to remain harbored in the
canals apical third (predisposing the case to failure), and blockage can
be a major factor in causing iatrogenic events (most commonly ledging
and separated instruments). Patency is most often obtained by using
small K le sizes of 6 to 15 after every rotary le just slightly (usually 1
mm) out the apical foramen to make sure that the canal path is clear to
its most apical extent. In some calcied and curved roots, it may be
necessary to irrigate and recapitulate after every K3 insertion to keep the
foramen open (Fig. 14).
Crown down instrumentation is desirable. Crown down instrumentation implies that the coronal third is instrumented rst, the middle third
second, and apical third last (Fig. 15). Using the K3 from larger to
smaller tips sizes (of the same or varying taper) incorporates crown
down instrumentation as each successively smaller le progresses
further down the canal passively. K3 les and the body shapers can
be taken to the true working length and used as the master apical le,

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147

Fig. 13. Removal of the smear layer with liquid EDTA (SmearClear, SybronEndo) after nal
irrigation with sodium hypochlorite is optimal.

but only where the le will progress smoothly to length. In delicate


apical anatomy, K3 les (as with any rotary nickeltitanium system) are
absolutely contraindicated unless preceded by creation of a glide path
with small K les (sizes 6 and 8) up to approximately size 15 to true
working length. In some canals, the apical third must be instrumented
by hand because curvatures can exist in both a mesial-distal and
a buccal-lingual plane, resembling a pigtail. Such canals are at risk for
le separation and are best judiciously treated by hand.
 Wipe the utes of the K3 after every use. Do not allow debris to build
up on the utes of the les.
 Do not force a K3 apically that resists advancement, especially in the
apical third. 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. Do not allow
the K3 to spin in place without apical movement for more than a second
at any level of the canal.
 Check the utes of these les after every use. If the K3 is bent or
stretched, has a shiny spot, or has other defects, discard it immediately.

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Fig. 14. Patency is important primarily because its loss causes signicant debris to remain
harbored in the canals apical third (predisposing the case to failure), and blockage can be
a major factor in causing iatrogenic events (most commonly, ledging and separated
instruments). (Courtesy of Arnaldo Castelucci, DDS, Florence, Italy.)

 Although the K3 can be used in more than one clinical case, as


mentioned previously, the les should not be employed a second time
after use in a canal of severe or abrupt curvature.
 Use an electric torque control motor with auto reverse to power the les
at the correct rpm. The TCM Endo III motor (SybronEndo) is such
a device. Clinically, most manufacturers have endorsed a rotational
speed of approximately 300 to 350 rpm for maximum eciency (Fig. 16).

K3 clinical technique
Coronal-third and middle-third management
Before making access, it is essential to radiograph the tooth from
multiple angles including mesial, straight buccal, and distal. Preoperatively,
an assessment of the number of roots, canal curvature, length of tooth,

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Fig. 15. Crown down instrumentation is desirable. Crown down instrumentation implies that
the coronal third is instrumented rst, the middle third second, and apical third last. The
diagramed instrumentation sequence ensures a crown down technique.

canal calcication, strategic tooth value, restorability, periodontal status,


access diculties, and so forth must be made. Such an evaluation will allow
the operator to anticipate diculties that might be encountered in
subsequent treatment, to preoperatively visualize the nal result, or to
determine whether treatment should be contemplated (Fig. 17).
After achieving excellent local aesthesia, access to the canal orice is
always straight line, with the common lateral dentinal triangle removed at
the cervical level in molars. Files never should deect o access walls as they
make their way into canals. The pulp chamber must be completely
unroofed.
After all the canal orices have been located, the orice is initially
enlarged with the K3 enhanced-tapered body shapers. Coronal-third
enlargement in larger canals (distal roots of lower molars, palatal canals
of upper molars, and so forth) will be accomplished with the 0.12; medium
canals (upper second bicuspids, upper central incisors, and so forth) will be
accomplished with the 0.10; and smaller canals accessed coronally with the
0.08 tapered les. For these smaller canals, after the 0.08 gains a toehold
in the canal, the operator can go back with a larger 0.12 and 0.10 body
shaper, enhancing access and coronal shape. The K3 body shaper is used to
light resistance, which is usually about 3 to 4 mm down the canal. Such

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Fig. 16. It is recommended to use an electric torque control motor with auto reverse to power
the les at the correct rpm. The TCM Endo III motor (SybronEndo) is such a device. Clinically,
most manufacturers have endorsed a rotational speed of approximately 300 to 350 rpm for
maximum eciency.

initial exploration should occur in the presence of an EDTA gel (especially


at the start of a vital case), and debris should be ushed away with sodium
hypochlorite (5.25%) and EDTA reapplied. Body shapers can be used as the
master apical le 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
les. The initial chosen body shaper (canal size dependent) is followed by
successively smaller tapered body shapers (ie, as each smaller tapered le is
used, it will advance further apically, ensuring a crown down sequence).
Used in succession, these three body shaping les alone may take the
operator to the junction of the middle and apical third or further, from
which the operator can then perform the nal apical preparation. These les
are ideal for achieving deep body shape (described later) because they are
highly fracture resistant, allow subsequent 0.02, 0.04, and 0.06 tapered K3
les greater penetration into the apical third than they could achieve alone,
enhance irrigation, enhance tactile control over the apical third, remove
coronal restrictive dentin, and create ideal canal preparation shapes.

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151

Fig. 17. (A) Before making access, it is essential to radiograph the tooth from multiple angles
(only the straight buccal is shown). (B, C) Subsequent treatment with the K3 system.

Clinical experience will dictate how much hand instrumentation will be


needed in the form of a glide path before using body shapers and K3 les of
all tapers. When the K3 body shapers fall easily into a canal, depending on
the clinical case, the glide path may not always be needed; however, in the
vast majority of teeth, it will. Conversely, in some narrow, severely curved
and calcied canals, it may be advisable in the middle third to rst scout
with size 6 to 10 K les to ensure canal patency before using body shapers,
even at this level. When a glide path is indicated, after canal location and
opening of the orice, the glide path is created by instrumenting canals by
hand with small K les in the middle third to a size 10 to15 K le before
proceeding with K3 les of all types at this level. After middle-third scouting
with K les, in general, a 0.06 K3 with a tip size of 35 (or the appropriate
body shaper) can be placed to at least midroot and, oftentimes, slightly
beyond. Despite the temptation to enter the apical third in these cases, it is
advised to take the K3 le only as far as it will advance without placing
excessive pressure on the le and not take it into the apical third yet. Taking
rotary les into the apical third without prior exploration with K les as
described later will increase the chance that the canal will become blocked
with dentin mud, a ledge will be created, or worse, the le will separate.
After middle-third scouting with K les, if the 0.06 K3 with a tip size of 35

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Fig. 18. Deep body shape is a key component of achieving control over subsequent apical-third
instrumentation and obturation. (A) A lack of deep body shape. (B) Subsequent retreatment
and its attainment.

(or the appropriate body shaper) will not progress to the desired level (the
junction of the middle and apical third), then a 0.06 K3 with a tip size of 30,
25, 20, or 15 can be employed instead. Recapitulation and irrigation should
be frequent as described earlier, ideally after every le.
Apical-third management and deep body shape
The apical third is the most challenging root canal anatomy to cleanse,
shape, and pack properly. Instrumenting the apical third rst, without
removing restrictive dentin in the more coronal two thirds, risks apical
blockage, underpreparation, and iatrogenic misadventure, among other less
than satisfactory outcomes. Coincident to the importance of crown down

Fig. 19. A recently introduced state-of-the-art fourth-generation apex locator (Elements


Diagnostic System, SybronEndo).

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153

instrumentation is the importance of creating deep body shape. Deep body


shape refers to the nal and ideal shape of a prepared canal at the junction
of the middle and apical thirds. This space might be considered the gate
keeper to the apical third. Deep body shape is a key component of achieving control over subsequent apical-third instrumentation and obturation.
The body shapers described previously are ideal for the creation of this deep
body shape to allow ideal irrigation, tactile control, recapitulation, and
attainment of hydraulic forces in the apical third during the vertical
compaction of warm gutta percha (Fig. 18).
Instrumentation in the apical third can only be done well using time,
patience, and a gentle touch as the watchwords. After the apical third is
opened (with deep body shape created), it often must be carefully explored
rst with hand instruments to determine (like the middle third before it) the
apical canal diameter, curvature, calcication, patency, and ease of
negotiation. Beginning with size 6 to 10 K les, 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. These K les should be entered passively and never forced to reach
a preconceived or estimated length. Using minimal apical pressure, the les
should be allowed to progress apically just as far as they want to go.
Maintaining canal patency and leaving the foramen in its initial position and
size is critical. After a size 10 or 15 K le reaches the estimated working
length, an apex locator reading should be taken and a radiograph exposed
to verify the correct length and make any necessary adjustments. Recently,
a state-of-the-art fourth-generation apex locator was introduced (Elements
Diagnostic System, SybronEndo) that is ideal for this purpose (Fig. 19).
This length can later be veried by a second apex locator reading after
instrumentation is complete (before obturation), a bleeding/moisture point
measured by way of paper points (as popularized by Dr. David Rosenberg,
Vero Beach, Florida) at the true working length, and a gutta percha master
cone-t radiograph. After true working length is established, a glide path for
subsequent K3 les is established to approximately a size 15 to 20 K le at
this length. Irrigation and recapitulation should be frequent.
After true working length is reliably established and the aforementioned
glide path is created, K3 les 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. 20). With either of these
methods, K3 les are introduced with larger to smaller tip sizes used in
a coronal to apical direction until true working length is reached. In the
method that varies tip size, for example, the 0.06 K3 les are generally
inserted from a size 35 (or larger) to a size 20 or 15 (canal size, curvature,
initial diameter of the apical foramen, and apical curvature dependent) and
the sequence repeated until the desired apical diameter is achieved (see the
following section, Gauging the apex). For smaller canals, the 0.04 K3

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series could be used in a similar fashion. It is noteworthy that 0.02 K3 les


of varying tip sizes can be introduced into the sequence as needed, especially
in small canals and to aid in creation of a glide path.
Gauging the apex
Before a master apical le can be selected, it is important to gauge the
apex, that is, to determine to what size the apex is patent. This technique is
best described by an illustration: if a size 25 K le slides to the true working

Fig. 20. K3 les are introduced in a crown down fashion with a sequence that either (A) varies
the tip size (with subsequently smaller K3 tip sizes) or (B) varies the taper (mixing the tapers of
the instruments as the tip size diminishes). ETBS, enhanced tapered body shapers.

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155

Fig. 21. The nal shape imparted to the canal by a given K3 le can be matched by a gutta
percha point (A) and a paper point (B) of the same taper (Autot gutta percha and paper
points, SybronEndo).

length and gives a resistance to apical displacement through the foramen,


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 t. Gauging the apex allows shape to
be created above the foramen while maintaining its size, location, and
patency.
The nal shape imparted to the canal by a given K3 le can be matched
by a paper point and gutta percha point of the same taper (Autot gutta

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percha and paper points, SybronEndo) (Fig. 21). A paper point of the
appropriate taper, if it will slide to length without deformation (after the
canal is dry), informs the operator of the actual taper of the prepared canal
and simplies cone t. A cone-t radiograph with the gutta percha point in
place before obturation conrms working length and appropriate preparation shape and is strongly recommended to assure the best results, even with
the information gained by way of the paper points used as detailed earlier.
These steps also facilitate subsequent obturation with the continuous wave
of condensation obturation technique (System B obturation with the System
B heat source, SybronEndo). After a cone-t radiograph and usually minor
adjustments, excellent obturation is possible for a multirooted molar in
a matter of minutes without the necessity of leaving a carrier as required in
carrier-based obturation techniques.

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 nickeltitanium le system is
used for coronal-third and middle-third shaping and the initial exploration
of the apical third, and LightSpeed rotary les (LightSpeed Technology, San
Antonio, Texas) are used for the nal apical preparation. Although K3 les
can be used to shape the entire canal including the apical third, some
practitioners prefer using the LightSpeed to create a larger nal apical
diameter (eg, the buccal roots of upper rst molars can be instrumented to
a size 50), giving rise to the K3/LightSpeed hybrid technique, blending the
two instruments. Intuitively, larger apical sizes, created judiciously, are
desirable. Such larger apical diameters can be associated with enhanced

Fig. 22. The hybrid technique. The K3 rotary nickeltitanium le system is used for coronalthird and middle-third shaping and the initial exploration of the apical third (A), whereas
LightSpeed rotary les are used for the nal apical preparation (B).

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157

irrigation, ease of cone t, and cleaner canals in the apical third by virtue of
the dentin and pulp removed at that level. The smooth shaft of the
LightSpeed les facilitates their use deep in canals with greater ease than
many other brands of rotary nickeltitanium les. Although the use of
LightSpeed les is detailed elsewhere in this issue, it is noteworthy that
before the employment of LightSpeed les to create a larger nal apical
diameter, the K3 should be taken to true working length, generally in a tip
size of 25 and taper of 0.06 (Fig. 22).

Summary
The K3 rotary nickeltitanium le system by SybronEndo is a state-ofthe-art rotary nickeltitanium endodontic instrumentation method that
combines excellent cutting characteristics with a robust sense of tactile
control and excellent fracture resistance. Although it is a complete instrumentation system, future possibilities for hybrid instrumentation techniques that combine the best features of K3 with other rotary systems (most
notably the LightSpeed) hold promise.

Acknowledgement
The author would like to thank Gary Carr, Pacic Endodontic Research
Foundation, Excellence in Endodontics 2, and the Digital Oce Program
for Endodontists.

References
[1] Bergmans L, Van Cleynenbreugel J, Beullens M, Wevers M, Van Meerbeek B, Lambrechts
P. Progressive versus constant tapered shaft design using NiTi rotary instruments. Int
Endod J 2003;36(4):28895.
[2] Shafer E, Florek H. Eciency of rotary nickel-titanium K3 instruments compared with
stainless steel hand K-Flexole. Part 1. Shaping ability in simulated curved canals. Int
Endod J 2003;36:199207.

Dent Clin N Am 48 (2004) 159182

Real World Endo Sequence File


Kenneth A. Koch, DMDa,*, Dennis G. Brave, DDSb
a

Real World Endo, The Barba Plaza, 2nd Floor, 2114 Silverside Road,
Wilmington, DE 19810-4448, USA
b
The Johns Hopkins Hospital, Baltimore, MD, USA

The past 10 years has been witness to many changes in endodontics, and
this trend will continue in the foreseeable future. The introduction of new
technologies has resulted in endodontics becoming easier, faster, and most
important, better. Paramount among these changes has been the introduction of nickeltitanium (NiTi) rotary instrumentation that results in
consistent, predictable, and reproducible shaping. This predictability of
shaping has not only inuenced instrumentation but also obturation results.
Primary cone t no longer needs to be a struggle. Machined, predictable
shaping now makes a primary cone t easy and precise. These changes are
certainly welcomed, but are there more advances on the horizon?
As previously mentioned, the authors are condent that signicant
change will continue to come to endodontics. The anticipated changes range
from the idea of disposable endodontic products to the concept of a true
hermetic seal when obturating the canal. Certainly not the least among the
changes is the issue of making endodontics not only better but also simpler.
The authors rmly believe that the more sophisticated a concept, the simpler
it should be.
As a result of this quest for a better, simpler technique, Real World Endo
in partnership with Brasseler USA has developed a new endodontic le and
sequence. It is hoped that this le and sequence will satisfy many of the
current demands of modern root canal therapy, while at the same time, be
user friendly. Before the specics of this new sequence le are discussed,
however, the benets of a fully tapered preparation must be reviewed.
When clinicians understand the rationale of a continuously tapered 0.06
preparation and perform it in a consistent manner, they will be stunned by
how quickly endodontics can become simpler and more predictable.
Real World Endo has been and continues to be a strong proponent of
a fully tapered 0.06 preparation. There are multiple benets to be gained
* Corresponding author. 23 Misty Meadow, Irvine, CA 92612.
E-mail address: HK5DENT@aol.com (K.A. Koch).
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.11.004

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from such a preparation. Before the authors evaluate the potential benets,
however, the issue of taper must be addressed.
A question that clinicians often ask is How am I going to place a 0.06
taper le into a space that I have had problems using a 0.02 taper? Isnt
a 0.06 taper le three times the width of a 0.02 taper?
The answer to the above question is no. A 0.06 taper is not just three
times the width of a 0.02 taper. The proof is in the arithmetic. Consider the
following example:
A size 20, 0.02 taper le (20/0.02) is 0.20 mm at a distance (D) of 1 mm
from the tip (D-1), and at D-10, the diameter is 0.40 mm. This number is
calculated by multiplying the taper (0.02) by the length (10 mm). The apical
tip size at D-1 (0.20) is added to the previously calculated number to get 0.40
mm. When the taper is increased from 0.02 to 0.04, it can be determined that
the width at D-10 for the new le is 0.60 mm. Interestingly, the taper
increased 100% (from 0.02 to 0.04), but the width at D-10 only increased
50% (from 0.40 to 0.60 mm).
If the apical size of the le at D-1 is increased to a size 40 (0.40 mm), the
diameter at D-10 for this le can be calculated to be 0.60 mm. Again, if the
taper is increased from 0.02 to 0.04, the diameter at D-10 for the 40/0.04 can
be determined to be 0.80 mm. So, although the taper increased 100% (from
0.02 to 0.04), the width at D-10 only increased 33.33%. This nding is even
more interesting. But what does this really mean?
It means that the eect of taper is inversely proportional to the apical tip
size; that is, as the size of the le increases, the eect of taper decreases. This
is very signicant because this is why a 0.06 taper rotary le can be used with
minimal problems. In addition, this is why a fully tapered 0.06 preparation
can be performed and still have a conservative preparation.
The knowledge of taper also allows the clinician to understand that there
are basically two ways to perform a root canal. The clinician can use
a sequence of les that employs a common tip size but has varying tapers
(eg, a 20/0.10 le followed successively by a 20/0.08, a 20/0.06, and
eventually a 20/0.04 le). The ProSystem GT employs such a variable taper
sequence, as do a number of other le systems such as Quantec and RaCe
(Brasseler USA, Savannah, Georgia).
A second option is to use a constant-taper le system, with variable tip
sizes (eg, a 35/0.04 followed by a 30/0.04, a 25/0.04, and nally a 20/0.04).
Two le systems that employ a constant taper are the Prole and the K3
(SybronEndo, Orange, California).
The authors agree with others who, in eect, have said that the biggest
obstacle to endodontic success is the step back preparation. The authors
could not agree more, and for the past 2 years, Real World Endo has been
trying to get this point across at lectures and in print. The authors, however,
would like to take this point one step further.
The authors strongly believe in using a constant-taper le sequence such
as a 0.04 or 0.06 taper to shape the root canal preparation. A variable-taper

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161

concept, in the authors opinion, does not work nearly as well clinically as it
does on paper. When one thinks about it, a variable-taper sequence is
nothing more than a step back preparation from the opposite end of the
tooth. As a result of better-quality manufacturing, clinicians now have
the ability, with a series of constant-taper les, to create predictable,
reproducible shapes. The variable-taper sequence results in a dierent shape
each time a root canal is done. The result is a lack of reproducibility that will
make obturation more challenging.
A total comprehension of taper is absolutely critical to clinicians interest
in increasing the quality of their endodontics; however, the question
remains, Why do endodontists prefer a continuously tapered 0.06
preparation?
There are a number of reasons for this preference. Two of the major
benets of the 0.06-tapered preparation are a dramatic reduction in
postoperative sensitivity for patients and the ability to have a precise cone
t. This combination leads to predictability, along with increased patient
satisfaction; however, there are other benets associated with a 0.06
preparation.
When performing a continuously tapered 0.06 preparation, the larger
taper removes the tooth structure in the coronal part of the canal that has
a tendency to bind instruments. Consequently, the removal of this tooth
structure results in a dramatic increase in proprioceptive ability. Therefore,
one benet of this technique is more tactile awareness. In addition, the
continuous 0.06 taper allows the irrigation agent to work in a more ecient
manner. How eective is the irrigation agent when a size 20 hand le
can hardly screw to length? It is not very eective; however, with a 0.06
preparation (performed in a crown down manner), the irrigation agent
is getting into the root canal system right from the start. The root canal
should be thought of as a three-dimensional system, with webs, ns, and
anastomoses. The only way these areas can be eectively cleaned is through
the use of an irrigation agent. The irrigation agent has the ability to work
much more eectively in a tapered 0.06 preparation compared with a 0.02 or
0.04 preparation. Canals that are preared with GatesGlidden burs (and
a 0.02 or 0.04 taper) do not do as eective a job with irrigation as a 0.06
preparation. In fact, GatesGlidden burs make a parallel preparation in the
coronal part of the canal. A continuous taper, on the other hand, has superior
hydraulics when it comes to irrigation. Furthermore, ultrasonics are particularly eective in a 0.06 taper preparation due to the continuous taper.
Another aspect of the 0.06 preparation that contributes to patient
satisfaction is the reduction in extruded debris. Quite often when performing
a root canal with hand les, debris is pushed out past the end of the tooth.
In a sense, this inoculates the periapical tissues. The sequelae of this is
increased postoperative sensitivity, if not pain and swelling. By using rotary
les that, by design, pull debris coronally rather than push it in an apical
direction, however, the amount of extruded material can be further reduced.

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The authors rmly believe that endodontics can be accomplished in


a truly painless manner. The 0.06 preparation is a signicant key to
achieving this goal.
Additional benets of this technique come after a fully tapered 0.06
preparation has been created: primary cone t and ease of obturation.
Instead of guessing, estimating, or becoming frustrated with bent cones, the
0.06 preparation makes the primary cone t a no-brainer. Naturally, this
becomes even easier when the main cone matches the preparation.
When live demonstrations at Real World Endo courses are performed,
the participants are always stunned at the ease of the cone t. It is not magic
but a result of the 0.06 preparation and having a precisely sized cone. The
news about performing a fully tapered 0.06 preparation, however, gets even
better.
The authors can condently state that whatever obturation method is
used, they all work better with a 0.06 preparation. Even the solid core
obturator systems such as Thermal work better with a 0.06 preparation
because the size no longer has to be veried.
Even though the authors have performed thousands of 0.06 cases, they
previously have been frustrated by one aspect. The authors have not been
able to successfully teach (to their satisfaction) this technique to the majority
of general dentists. This inability is because the previous 0.06 tapered les
had a tendency to be sucked down into the canal or were quite sti.
Consequently, the general practitioner has had a tendency to use 0.04 taper
les or les with variable taper. (It is the authors belief that a 0.04 taper
preparation should be performed only when the situation does not allow
a fully tapered 0.06 preparation.) The authors hope to change this tendency
with the introduction of the Real World Endo Sequence File. True
appreciation of this le is gained when its design features are fully
understood and it is actually used clinically.
All endodontic companies are trying to produce les that will work more
eciently and safely; however, there remains tremendous variability between
the dierent les. In fact, as more rotary les enter the marketplace, there
seem to be greater dierences and less in common between the les. Some of
the areas where le design diers is in blank design, metal treatment (or lack
of), quality of NiTi manufacturing, taper, tip design, cutting eciency,
resistance, exibility, pitch, helical angles, and speed requirements.

General rotary le design


Blank design
NiTi rotary les are ground, not twisted, during the manufacturing
process. Consequently, there are fairly signicant dierences between the
various les. Most les are symmetric in their blank design, although some

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163

have an asymmetric design such as the K3 by SybronEndo. Although the


majority of rotary les have blanks that create signicant engagement
against the dentinal walls, there are other les such as the RaCe that have an
alternating spiral design and, therefore, reduced engagement. The blank
design of a le is very important because it will inuence the exibility of the
le and the lateral resistance. The greater the resistance, the more torque
is required to work the les properly. This concept is important because
it must be remembered that excessive torque is one of the key factors in
instrument separation.
Metal treatment
Metal treatment has been greatly underused in the manufacture of NiTi
rotary les. Currently, there are very few companies doing metal treatment
of any nature to their rotary les. Surely, most companies know the benets
of metal treatment procedures such as cryogenics or electropolishing. The
concept behind the metal treatment of rotary les is that such procedures
can extend the life of a rotary le, making it a better le.
For example, electropolishing will dramatically reduce the potential for
crack propagation in NiTi les. This process is very signicant because it has
been repeatedly shown that crack nucleation and propagation is a leading
cause of unexplained instrument separation.
Quality of manufacturing
The adage you get what you pay for can be applied to endodontics. In
fact, there are dierent quality NiTi blanks that are available for
commercial purposes. Some manufacturers use NiTi blanks that exhibit
extreme exibility and excellent shape memory. Other manufacturers
employ NiTi blanks that are sti and actually seem to hold a curve. The
quality of the NiTi blank is a little-known factor of le design but one that
has serious consequences.
Additional aspects of the quality of manufacturing can be seen if the
handle of the le being used comes o during engagement. A good test of
the quality of a le is to turn the le around and look straight down on the
le as it is rotating in the handpiece. Is the le running true (tight concentric
revolutions) or is there a wobble? A wobble signies a less than ideal
manufacturing process.
Taper
The majority of manufacturers produce rotary les that come in a variety
of tapers. Depending on the blank design, however, certain rotary les can
become extremely sti in tapers greater than 0.04. In addition, some
companies are also producing rotary les in a 0.02 taper, which is the same
International Standards Organization taper size as a hand le. Although

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a 0.02 taper may work well in the hands of certain specialists, the authors
believe that using 0.02 taper rotary les is a serious mistake for most
clinicians. A 0.02 taper rotary le is so small and exible that it can easily get
pulled into the small radius curvatures present in the apical third of many
teeth. Small radius curvatures are a common cause of instrument breakage.
If a clinician needs to use a 0.02 taper le, the authors recommendation is to
use a hand le. Real World Endo feels very strongly about this issue because
their goal is to not only make instrumentation more ecient for the clinician
but also maintain safety at all times.
Tip design
Tips have been described as either cutting tips or noncutting tips. Some les
claim to have modied cutting tips or partially active tips. Others have
guiding tips. These claims are all a bit of semantics because a tip can actually
be noncutting at the true tip but may become active before D-1 on the shank.
Nonetheless, the greatest safety cushion is aorded with noncutting tips.
Is there a place for a cutting tip on a rotary le? The answer is yes;
however, cutting tips have a limited indication in endodontics and should be
used only in the hands of an experienced clinician. As previously mentioned,
Real World Endo believes that most dentists are best served using a rotary
le with a noncutting tip. The authors are very condent about that
statement. Although some experienced clinicians may be able to use cutting
tips, the authors believe that they are too aggressive for most practitioners.
There are two serious concerns with a cutting tip. The rst is if the
clinician accidentally goes long (past the end of the tooth). Going long
with a noncutting tip will create a concentric circle at the end of the root.
These spaces are easily lled with a nonstandardized or tapered cone;
however, if the clinician goes long with a cutting tip, when the le is
retracted, an elliptical tear is generally created. This tear is very dicult to
repair and obturate, even for a specialist. Furthermore, a cutting tip on
a nonlanded le, or a le that does not have a self-centering ability, has the
very real possibility of transportation.
Cutting eciency
Cutting eciency of rotary les is an area that has received much
attention in the past few years. The more ecient a rotary le, the less
torque is required. Most manufacturers are attempting to address this
challenge. Rotary les with full radial lands and a neutral rake angle have
modest cutting eciency. Rotary les with a positive rake angle and
recessed radial lands may have seemingly better cutting eciency. Depending on where a rotary le is sectioned, however, the rake angle can, in fact,
be dierent. The entire issue of rake angles continues to be one of
controversy in endodontics.

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Alternately, les that employ a modied triangular bade design and


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

Fig. 1. Precision tip after electropolishing.

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radial lands sacriced cutting eciency along with creating increased


resistance (torque).
Flexibility
Flexibility is a design feature that received a lot of attention when rotary
les rst entered the marketplace. Throughout the years, the exibility of
NiTi les has become a given; however, this is not truly the case. There is
tremendous variation in exibility among the various rotary les. Although
it is true that design features can eect how well a le performs, exibility
still remains a critical factor for rotary les.
Many things can eect exibility, such as the manufacturing process,
blank design, and the presence and width of radial lands. The authors
strongly believe that if clinicians are treating dicult endodontic cases in
their practices, then they need a le with excellent exibility. It is as simple
as that. Flexibility is not as critical in straight canals or teeth with very
modest curvatures.
Pitch/helical angles
Pitch is the number of spirals or utes per unit length. Pitch is very
important because a constant pitch will work much like a wood screw and
pull you into the tooth. A variable pitch, on the other hand, will signicantly
decrease the tendency of the le to get sucked down into the tooth. This is
especially signicant when using tapers of 0.06 or greater. Interestingly, it
does not matter how the pitch is varied, so long as it is variable.
Variable helical angles are also an important aid to moving debris up and
out of the canal. One can actually see debris moving up along the shank of
the le that has variable helical angles. A constant helical angle le is more
prone to debris accumulation. This debris accumulation can lead to the need
for increased torque, which can lead to potential separation.
Speed
Concerning speed and its inuence in rotary instrumentation, the authors
would like to propose a formula. E = S & T, where E, the energy required
to remove dentin, is a function of both speed (S) and torque (T ). As you
decrease the torque requirements, one may increase the speed. Basically, this
concept means that a le will run better at a higher rate of speed (within
reason) than at a lower rate. Although the higher rate of speed may be
benecial, it also decreases the cycles to failure (ie, the le cannot run as long
before the onset of cyclic fatigue). It has been the authors experience to
observe that clinicians usually run rotary les at too slow an rpm, not at too
fast a rate.

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Having discussed the design features of rotary les, in a general sense, the
features of the new Real World Endo Sequence File are specically examined.

Real World Endo Sequence File design


Blank design
The blank design of the Sequence File is absolutely revolutionary. It is
designed in such a way that there are alternate contact points (ACPs) along
the shank of the instrument. This innovative design not only keeps the le
centered in the canal but the ACPs also greatly reduce the torque
requirements of the le. This is because ACPs greatly reduce the resistance
of the le (Fig. 2).

Fig. 2. (A) Sequence File with ACPs. (B) Diagrammatic representation of ACPs.

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There are other signicant features to the ACP design. Because the ACPs,
in combination with a precision tip, keep the le centered in the canal, there
is no need for radial lands. This design change is profound because the lack
of radial lands allows the instrument to be sharper and, consequently, more
ecient. In addition, the lack of radial lands results in a decreased thickness
of metal. The result of less metal is a dramatic increase in exibility.
Clinicians will be amazed at how exible a fully tapered 0.06 rotary le can
be when not burdened by the excessive metal that is needed for radial lands.
Metal treatment
Another admirable feature of the Sequence File is that it has been
subjected to the process of electropolishing, which is very signicant because
of the benets gained from such a treatment.
Electropolishing removes many of the imperfections in the NiTi that can
have catastrophic consequences. For example, electropolishing is very
eective at inhibiting crack propagation in NiTi blanks. These cracks have
been shown repeatedly to be a major cause of instrument separation. In
addition, the creation of a superior nish will keep the edge of the NiTi
instrument sharper, cleaner, and more durable. The result of these benets is
a rotary le with more cutting eciency, less lateral resistance, and increased
resistance to wear. Electropolishing can extend the life of a rotary le, but
the Sequence File has been designed to be part of a single-use system. Simply
put, electropolishing makes any rotary le safer and better (Fig. 3).
It also must be noted that at the current time, the Real World Endo
Sequence File is the only constant-taper rotary le system that is subjected
to an enhancement procedure such as electropolishing. The authors believe
that this is a signicant advance in the manufacturing of constant-taper les.
Quality of manufacturing
It is not sucient to say that just because something is Swiss-made, it
means that it is excellent; however, there is a certain connotation to Swissmade and the authors believe that the proof is in the pudding. Real World
Endo is committed to the concept of Precision-Based Endodontics, and
this precision is a function of the quality of manufacturing.
On thorough inspection of a Sequence File, by rotating it slowly and
checking the consistency of rotation, one should see a shadow consistently
climbing up the helical angles from the tip to the handle. After inspecting
the edges, one can conrm the sharpness: when the le is pulled across
the ngernail (cuticle to tip), it will bite and engage. The sharp edges are
a function of its manufacturing process.
On inspection, one can also conrm the exibility of the Sequence File and,
more important, the shape memory of its NiTi blank. The shape memory is
superb. It is next to impossible to separate the handle from the shank.

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169

Fig. 3. (A) Pretreatment view. (B) After traditional polishing. (C) After electropolishing.

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K.A. Koch, D.G. Brave / Dent Clin N Am 48 (2004) 159182

It is with supreme condence that the authors can say that the Sequence
File has been manufactured to the highest possible standards. The authors
challenge any other manufacturer to meet these simple yet rigorous
standards.
Taper
The Real World Endo Sequence File is available in both 0.04 and 0.06
tapers. Most important, these are fully tapered les, which means that the
working shank is 16 mm, not a reduced 9 or 10 mm. A full working shank is
signicant because it will allow the practitioner to machine a preparation
in a precise, crown down fashion. Not only will this technique contribute to
painless endodontics but it also will make the primary cone t an easy
match. Obturation becomes much easier when you have a fully tapered
machined preparation.
Tip design
It is a goal of Real World Endo to have clinicians perform not only
ecient endodontics but also safe endodontic procedures. Consequently, the
Sequence File uses a precision tip. A precision tip, by denition, is
a nocuutting tip that becomes active right at D-1. The result is safety
(nonperforating) combined with eciency. This is exactly what we want to
have in a tip design (see Fig. 1) It is truly amazing how such an eective
cutting le can remain centered in the canal. This ability to remain centered
is the result of a precision tip combined with ACPs of the blank design. This
concept is a new and revolutionary one.
Cutting eciency
The Sequence File has superb cutting eciency. The only other le that
the authors have seen with a similar eciency is the ProTaper. Although the
ProTaper also employs a triangular bank design, it is somewhat modied.
What gives the Sequence File extra cutting eciency is the electropolishing
that results in its characteristically sharp edges. Furthermore, the ACP
design allows the portion of the instrument that is engaged to really work in
an ecient manner because the full shank is not totally engaged and there is
no encumbrance of radial lands.
Experience has shown that the Sequence File cuts so eectively that the
operator must be aware to wipe clean or change the le after three pecks (or
engagements) of the le. After a brief period of time (3 to 5 seconds), the
operator can actually see the utes (which are a reamer design) begin to
accumulate debris. This accumulation is a result of the les superb cutting
eciency. Consequently, the operator and the assistant need to be
conscientious about cleaning the le. The le should be in the canal only
for 3 to 5 seconds before cleaning.

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

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Speed
The Sequence File has been shown, through test cases (both clinically and
bench top), to work best in a range of 450 to 600 rpm. The ideal speed may
vary a little according to clinician preference and engine. Every engine the
authors have worked with seems to have an optimal rpm for specic les.
This concept is analogous to marine engines in which a boat will plane and
perform smoothly at a certain rpm, but at other rpm, the boat will
experience some noise and vibration.
The authors personal preference is 600 rpm, which they have found to
work well in multiple engines. The authors particularly like the way this le
performs in a portable engine (Fig. 4).
Historically, portable engines have been challenged when running fully
tapered 0.06 rotary les because the radial lands on the previous generations
of rotary les produced excessive lateral resistance. Due to the ACP design
(no lands) and its lack of torque requirements, however, the Sequence File
runs superbly in a portable handpiece.
It also is a goal of Real World Endo to remove as many rheostats as
possible from the treatment room. The day is coming when clinicians will be
able to perform rheostat-free endodontics.
It must also be pointed out that the Sequence File has a tendency to click
in the canal. In the past, this clicking might have been cause for alarm;
however, it is not unusual for a triangular-shaped blank. If the clicking
becomes a clacking (or clearly noisy), however, then it means that you are
pushing too hard on the le. The clacking will disappear when the le is not
pushed as hard. The rpm should not be reduced because the clacking is
a result of excessive force, not rpm.

Fig. 4. Brasseler Sequence File portable handpiece.

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173

In the authors experience, rotary les that are run at too low a speed
(150175 rpm) result in increased breakage. This breakage takes place
because the le is going so slowly that there is a tendency for the clinician to
force the le. A le should never be forced. By running the handpiece at the
proper rpm (450600 rpm), the clinician can let the le do the work.
Now that the design features of the Sequence File have been discussed,
the following section addresses clinical technique.

Real World Endo Sequence File technique


The Real World Endo Sequence File comes in packages of four les each.
The selection of Sequence Files includes an Expeditor le (four to a pack)
and 0.06 taper rotary les in sizes extrasmall/small, medium, and large. In
addition, there are 0.04 taper Sequence Files available in sizes extrasmall/
small and medium.
All root canal preparations are begun by conrming coronal patency.
This conrmation is achieved with a size 10 stainless steel hand le that is
taken down half way into the canal. Coronal patency is important because if
the coronal half of the canal is open (patent), then it will be open all the way
to the apex. After reaching the halfway point in the canal, the size 10 le is
worked in a back and forth motion to ensure a glide path. If the canal is
extremely tight, then the clinician may also wish to use a size 15 hand le.
After coronal patency has been conrmed, an Expeditor le is the rst
rotary le placed into the canal. The use of an Expeditor is a new concept,
using a totally dierent le. The Expeditor is a size 27, 0.04 taper rotary le
that incorporates a working shank of 16 mm and an overall length of 21 mm
(Fig. 5). The purpose of the Expeditor is to determine the approximate size
of the canal and which package of les should be opened. The authors have
given the Expeditor an overall length of only 21 mm so that the clinician
does not get tempted to bury the le deep into the canal (ie, eciency
combined with safety).
After entering the canal with the Expeditor, this le is taken down into
the canal until signicant resistance is encountered. Signicant resistance is
when the le no longer progresses in an easy manner. Having met resistance
with the Expeditor, this le is now removed from the canal, and the operator
chooses which package of les to open. This decision is based on
information gleaned from the preoperative radiograph, the resistance of
the size 10 hand le, and the depth of penetration of the Expeditor.
When the Expeditor goes down halfway into the canal, it signies a small
canal; however, when the Expeditor goes down more than halfway, it means
the canal is medium sized. A totally loose Expeditor that goes to its entire
length signies a large canal. After the canal size is determined, the operator
simply picks the appropriate pack of les.

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Fig. 5. Sequence Expeditor le.

For example, in a narrow canal, the package of extrasmall/small les may


be chosen. After choosing the appropriate Sequence File, a crown down
technique is performed in the recommended manner. For example, in a small
canal, beginning with a size 30, 0.06 taper (30/0.06) le, the author takes that
to resistance. Following the initial le, a 25/0.06 Sequence File and then a 20/
0.06 le are taken to resistance. Quite often, the 20/0.06 Sequence File will
take the author to the working length. The question remains, however,
How do you know when you are nished? The crown down preparation is
complete after the rst rotary le that reached the working length with
resistance has been used.
There will be times, however, when the 20/0.06 Sequence File falls short
of reaching the working length with resistance. In this case, crown down
should be continued to a 15/0.06 le, and generally, this le should take the
clinician to the nal working length. If the canal is narrow and the clinician
must crown down all the way to the 15/0.06 le, the authors suggest that the
preparation should not be nished with this size instrument. It is better to

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175

simply go back into the canal with a 20/0.06 Sequence File, which will
readily go to the working length. This procedure is easily accomplished
because the Sequence le is extremely ecient at enlarging a previously
created glide path.
The aforementioned technique works very well for the overwhelming
majority of cases; however, in extremely dicult, narrow canals, the authors
slightly modify the technique to reduce stress on the le.

Real World Endo Sequence File technique for extrasmall canals


As always, the clinician begins by conrming coronal patency with a size
10 stainless steel hand le. This step is extremely important when treating
narrow canals. It is also suggested to take a size 15 hand le into the
canal and create a glide path. This procedure will facilitate the rotary
instrumentation in such canals. Following the use of the hand le, the
Expeditor is introduced into the canal. The Expeditor is worked down into
the canal until signicant resistance is met. Following the use of the
Expeditor, the clinician should open the package of les labeled extrasmall/
small.
The crown down procedure can begin, but with one modication. A
modied crown down sequence will be substituted for a straight crown
down.
The modied crown down preparation begins with a size 25, 0.06 taper
(25/0.06) Sequence File, taken to resistance. Generally, this le goes down
the canal about 15 mm and should be followed with a 30/0.06 Sequence File.
This le will generally go 1 to 2 mm less. After two les, the coronal half of
the canal has been successfully preared. The nal working length may now
be determined with a size 10 stainless steel le and an apex locator. The
clinician may chose to create a glide path to the apex with a size 10 or size 15
hand le. Following length determination, the clinician returns to the
original 25/0.06 le and works this le to resistance. Instead of just going to
15 mm, however, it now tracks down to about 18 mm. This increased length
is what is so eective about this technique. Following this step, the clinician
takes the 20/0.06 le to resistance. Often, the size 20 will reach the nal
working length. If not, the crown down should be continued with a 15/0.06
le, which will generally reach nal working length. As previously
mentioned, when crown down must go all the way to size 15, the authors
recommend looping back with a 20/0.06 Sequence File and taking this to
length. The authors do not advocate nishing the preparation with a size
less than 20. This applies to both 0.04 and 0.06 fully tapered preparations.
Although the modied crown down works extremely well in dicult
cases, one further change can make the technique easier: performing this
technique with 0.04 taper rotary les instead of 0.06 taper instruments.

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Fig. 6. Case 1. (A) Failed 0.02 taper hand ling case. (B) Successful retreatment with 0.06 taper
rotary les.

Often, this change is exactly what is needed to instrument these challenging


cases (ie, it is all a function of taper).

Summary
In review, the entire Real Word Endo Sequence File technique is based
on the concept of using an Expeditor le and then choosing the size of the
canal. The canal size is either small, medium, or large, and each corresponding package contains the four les necessary to properly shape the

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177

Fig. 7. Case 2. (A) Preoperative radiograph of mandibular molar. (B) Postoperative radiograph
showing machined preparations. (Courtesy of Dr. Ali Nasseh.)

canal. Generally, the canal preparation will require only three les, but
a fourth le has been included for challenging cases (Figs. 610).
Although the Sequence File is unique in being both procedural and
precision based, it is also dierent in terms of its handling ability. It is
a rotary le, and like all rotary les, it should not be forced. As previously
mentioned, if this le is muscled, then a clacking of the instrument is
heard. This is a heads-up to reduce the pressure on the le. When the
proper technique associated with this le is learned, however, the clinician

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Fig. 8. Case 3. (A) Midroot area on mandibular premolar. (B) Working lm displays
precision of preparation. (C) Postoperative radiograph. (Courtesy of Dr. Ali Nasseh.)

will realize that it is merely a matter of guiding the instrument. This is


a result of its superb cutting ability. In addition, the unique ACPs gives this
le an unbelievable feel. The canal can actually be felt with the Sequence
File. This change from some of the previous rotary les that were sti and
lacking in sensitivity is a welcome one.
The clinician needs to establish a rm nger rest when using rotary les.
This concept also is important with the Sequence File; the entire procedure
can be made very comfortable when combined with a portable handpiece.

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179

Fig. 8 (continued )

The Sequence File is not used like previous rotary les that had
radial lands; that is, the le is not taken to resistance and back, to resistance and back, and so forth. The Sequence File also is not used with short
staccato-like pecks. Instead, it is used in a single 1-2-3 motion. The le
is taken to engagement (1) and back, to engagement (2) and back, and
nally to a third engagement (3), and out of the canal. The clinician
will very quickly learn this rhythm. It is the rhythm of precision
endodontics.
Always clean the le after three engagements. It is recommended that the
clinician perform two series of three engagements each before going to the
next le. Each series of engagements should take approximately no more
than 3 to 5 seconds.
What is meant by engagement? When performing this technique, the
clinician can actually feel the Sequence File engage the walls of the canal and
begin to work. As soon as the clinician feels the le engage, the le should
be slightly retracted (12 mm) and then reinserted for another engagement.
By using this technique, the clinician is instrumenting the canal millimeter
by millimeter.
The portable handpiece allows clinicians to work strictly with their
ngers (thumb to middle nger). So, instead of controlling the le from the
wrist area (as is done with thicker, landed les), we now have, for the rst
time, a rotary le that is controlled by nger tip pressure. This adds greatly
to the overall control of the procedure and will more easily allow the
clinician to achieve Precision Based Endodontics.

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Fig. 9. Case 4. (A) Preoperative radiograph of maxillary bicuspid. (B) Completed case showing
conservative aspect of machined preparations. (Courtesy of Dr. Emanuel Alvaro.)

The following list reviews the basic Real World Endo Sequence File
technique:
1.
2.
3.
4.
5.
6.

Conrm coronal patency.


Use Expeditor to determine canal size.
Begin crown down.
Establish working length after second le from Sequence File package.
Complete crown down.
Obturate the canal.

The following list reviews the basic Real World Endo Sequence File
technique (straight crown down):
1. Conrm coronal patency with a size 10 stainless steel hand le. The le
only needs to go to approximately one half of the projected working
length. If a canal is patent in the coronal third, then it usually will be

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181

Fig. 10. Case 5. (A) Preoperative radiograph of molar. (B,C) Working lm displaying precision
of Sequence File cone t. (Courtesy of Dr. Ali Nasseh.)

open to the apex. Too many dentists make the mistake of trying to force
a hand le to length before coronal aring.
2. Determine canal size based on the preoperative radiograph, the t of the
size 10 stainless steel hand le, and the depth of penetration of the
Expeditor. Canal size is generally small, medium, or large.
3. Begin crown down with a le from the appropriate le-size package.
4. Establish working length with a size10 hand le and an apex locator
after using the second rotary le from the package. Determine working
length after the second rotary le to take advantage of the crown down.

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Fig. 10 (continued )

5. Complete rotary preparation in a straight crown down fashion. The rst


Sequence File to length, with resistance, completes the preparation.
6. Obturate the canal with the technique of your choice.

Dent Clin N Am 48 (2004) 183202

The hybrid concept of nickeltitanium


rotary instrumentation
Helmut Walsch, MS, Dr. med. dent.*
Department of Endodontics, School of Dental Medicine, University of Pennsylvania,
240 South 40th Street, Philadelphia, PA 19104-6030, USA

The development of nickeltitanium (NiTi) rotary instruments is


undoubtedly a quantum leap for the eld of endodontics. Nevertheless,
those who have gained some experience in the use of such instruments will
conrm that each le system has its own special advantages and disadvantages and that particular rules for its usage need to be followed.
With most NiTi systems, it is easy to reach working length and prepare the
apex to a small size such as International Standards Organization (ISO) size
20. When the apex is prepared to larger sizes, however, the limits of a
particular system quickly become apparent. The idea of the hybrid concept is
to combine instruments of dierent le systems and use dierent instrumentation techniques to 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 dierent systems for
safe, quick, and predictable results.

Nickeltitanium rotary instrument systems


Some NiTi rotary instrument systems that presently can be used for this
hybrid concept are introduced here, and their main features are described.
Among these systems, two main categories of NiTi rotary instruments need
to be dierentiated: active and passive instruments. Active instruments have
active cutting blades similar to the K-FlexoFile (Fig. 1A), whereas passive
instruments have a radial land between cutting edge and ute (Fig. 1B). The
radial land touches the canal wall on its entire surface, guiding the
instrumentstable and balancedwithin the canal. In general, active

* Heiterwanger Strasse 6, 81373 Munchen, Germany.


E-mail address: hewalsch@yahoo.com
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.11.003

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H. Walsch / Dent Clin N Am 48 (2004) 183202

Fig. 1. File cross-sections. (A) K-le, RaCe. (B) ProFile, GT, LightSpeed. (C) Hero 642. (D)
K3. (E) ProTaper, Flexmaster. (F ) ProTaper F3.

instruments cut more eectively and more aggressively and have a tendency
to straighten the canal curvature. In addition, the more positive the rake
angle of the blade, the more aggressive the cutting action of the instrument.
Passive instruments perform a scraping or burnishing rather than a real
cutting action, remove dentin slower, and have less of a tendency for canal
straightening.
Key features of all instruments introduced here are three blades and
a passive, noncutting tip. ProFile (Dentsply Tulsa Dental, Tulsa,
Oklahoma), GT (Dentsply Tulsa Dental), LightSpeed (LightSpeed Technology Inc., San Antonio, Texas), and others belong to the family of passive

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H. Walsch / Dent Clin N Am 48 (2004) 183202

instruments. Flexmaster (VDW, Munich, Germany), RaCe (Brasseler USA


Savannah, Georgia), ProTaper (Dentsply Tulsa Dental), Hero (MicroMega
SA, Besancon, France), K3 (SybronEndo, West Collins Orange, California),
and others are active instruments.
Representatives of passive instruments
ProFile instruments come as ISO-sized instruments with a taper of 0.06 in
size 15 to 50, a taper of 0.04 in size 15 to 80, and a taper of 0.02 in size 15 to
45. Also available are Series 29 ProFiles for which the increase in size is 29%
from one instrument to the next. They come in 0.04 and 0.06 tapers from
size 2 (0.129 mm) to 10 (1.0 mm) (Table 1).
GT les for crown down and apical preparation have undergone several
size modications. At present, they come as sets of dierently tapered
instruments and constant tip sizes (20, 30, and 40). The size 30 and 40 sets
consist of four instruments with tapers of 0.10, 0.08, 0.06, and 0.04. The size
20 set consists of ve instruments with an additional taper of 0.12.
LightSpeed, in contrast to these instruments, features a design similar to
that of a Gates-Glidden (GG) bur. It has a small cutting head with minimal
cutting surface and has a thin parallel shaft. These instruments come in
half sizes from 20 to 70 and in full sizes from 80 to 100. Their crosssection through the cutting head is similar to that of a ProFile or a GT le
(see Fig. 1B). LightSpeed instruments are used in a pecking motion with
higher rotational speeds than all other NiTi rotary instruments. When using
LightSpeed, no instrument size must be left out. The main advantage of this
system clearly is its undefeated ability to manage curves with large instrument sizes because of its shaft exibility. LightSpeed instruments have been
shown to maintain severe canal curvatures [1], and even large apical preparations can be performed with little deviation [2]. 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.
Table 1
Series 29 instrument sizes
Size No.

Size (mm)

Color code

2
3
4
5
6
7
8
9
10

0.129
0.167
0.216
0.279
0.360
0.465
0.600
0.775
1.000

Silver
Gold
Red
Blue
Green
Brown
Silver
Orange
Red

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H. Walsch / Dent Clin N Am 48 (2004) 183202

Representatives of active instruments


RaCe instruments come in the following taper/size combinations: as PreRaCe instruments0.10/40, 0.08/35, 0.06/30 and 40; and as RaCe instruments0.06/20 to 30, 0.04/25 to 35, 0.02/15 to 40 and 50 and 60. Their
cross-section is triangular with large utes (see Fig. 1A). These instruments
are very exible. Their main feature is that the helical angle after some
revolutions has short interruptions (becomes 0 ), whereby the blades are
straight for a short distance and parallel to the long axis of the instrument
(alternating cutting edges). The purpose of this feature is to reduce the
screw-in eect of the instrument.
When an active instrument is rotating within a curve with a small radius,
a clicking sound can sometimes be heard. One reason for this clicking could
be that the le breaks loose the dentin into which it was engaged. Another
possible reason is the following: during the rotation of a le in a considerably
curved root canal, from the moment when the blade touches the inner wall
of the elbow of the curve to the moment when the ute is touching that
point, the instrument straightens slightly. While the le continues to rotate
coronal of the elbow of the curvature, it stands still at the elbow with the
ute 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. This jumping from ute to
ute can cause the clicking noise.
The utes 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 straight part (straight utes, no helical angle) of
a RaCe instrument might touch the inner surface of an elbow at a longer
distance, causing more straightening of the le compared with a regular le.
The amount of torque needed to cause the instrument to jump may be
higher. The particularly high exibility of RaCe instruments, however, may
compensate for this eect.
Hero 642 instruments come in tapers of 0.06 and 0.04 in sizes 20 to 30 and
in taper 0.02 in sizes 20 to 45. Hero Apical instruments are accessory
instruments for apical enlargement. They come in tapers 0.06 and 0.08 in
size 30 and have short cutting areas. The cross-section of Hero instruments
is shown in Fig. 1C. These instruments are relatively exible. The recommended usage, called the three wave concept, follows the idea of
varying the instrument tapers [3].
K3 instruments come in 0.06 and 0.04 tapers in sizes 15 to 60. Fig. 1D
shows their cross-section, revealing that these are very strong instruments.
FlexMaster instruments come in tapers of 0.06 and 0.04 in sizes 20 to 40
and in taper 0.02 in sizes 20 to 70. They have a convex triangular crosssectional form, shown in Fig. 1E. These instruments are relatively strong.
ProTaper instruments have a convex triangular cross-sectional form, very
similar to that of FlexMaster (see Fig. 1E), and also are relatively strong.

H. Walsch / Dent Clin N Am 48 (2004) 183202

187

ProTaper instruments are unique among all NiTi rotary instruments in that
they have dierent tapers along a single instrument (multitapered instruments). The set consists of six instruments: three shaping instruments (SX,
S1, S2) and three nishing instruments (F1, F2, F3). The main dierence
between the S and F instruments is that S instruments have an increasing
taper from tip to top, whereas the F instruments have a decreasing taper
from tip to top. Shapers mainly cut in the middle third of the root canal with
their tips, following the glide path so as to create an access for the nishers
that will cut in the apical third of the root canal. A set of ProTaper
instruments used sequentially will only cut along a short distance in the
canal, touching little canal wall surface. This eect will reduce the torque
load and increase the cutting eciency of each individual instrument. The
convex utes of the largest instrument (F3) have been cut out to a more
convex form, reducing the stiness and increasing the exibility of this
strong instrument (Fig. 1F). The tip size of F3 is 30; the taper at 3 mm from
the tip, however, is 9%. At 2 mm from the tip, the diameter is size 48; at
3 mm, it is size 57.

Nickeltitanium instrumentation rules


To increase the safety of NiTi rotary instrumentation techniques, some
basic rules should always be obeyed. The following most important rules
apply for the use of any NiTi rotary instruments:
The lowest recommended rotational speed seems safest [4,5].
Use le lubrication (RC-prep [Premier Dental, Plymouth Meeting,
Pennsylvania] or similar).
Support operators hand at the neighboring teeth to compensate for
patient moving, increase le control, and avoid the screw-in effect.
Keep canals ooded with sodium hypochlorite during instrumentation.
Use no apical pressure.
Rotate les continuously.
Minimize cutting time.
Make each le insertion deeper with the same le.
Withdraw immediately at desired length.
Clean and check les after each insertion.
Irrigate, recapitulate, and reirrigate after each le insertion.
Check patency frequently.
Most of these rules seem even more critical for active instruments than
for passive ones. Active instruments can lead to procedural errors faster
than passive ones in inexperienced hands.
Experience using the instruments on extracted teeth before clinical use is
mandatory. It has been shown that with increasing experience, the frequency
of instrument deformations and fractures decreases [6].

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H. Walsch / Dent Clin N Am 48 (2004) 183202

To understand the concept of a hybrid sequence of biomechanical instrumentation, three dierent approaches to enlarging a root canal (crown down,
step back, and apical widening) are summarized in the following sections.

Crown down
The crown down idea is to step apically by using a series of les while
decreasing instrument size or instrument taper. The next smaller le will
perform its cutting action deeper in the canal, leaving the engaging surface
of each instrument minimal and, therefore, decreasing the torque load of
each instrument. Repeating the use of such a series of les will also result in
either gaining deeper access into the canal or enlarging the canal further by
each sequence. Fig. 2 shows the decreasing taper approach with a classical
GT le set. The tip size of each instrument is ISO 20, with tapers of 0.12
(blue), 0.10 (red), 0.08 (yellow), and 0.06 (silver). The arrows in Fig. 2
indicate the areas where the individual instruments engage the dentinal
walls. Crown down minimizes coronal interference, eases instrument

Fig. 2. Crown down approach with decreasing taper. Arrows indicate corresponding cutting
area.

H. Walsch / Dent Clin N Am 48 (2004) 183202

189

penetration, increases apical tactile awareness, reduces canal curvature,


minimizes change in working length during apical instrumentation, allows
irrigation penetration to preparation depth, removes bacteria before
approaching the apical canal third (therefore preventing iatrogen apical
contamination), reduces the contact area of each instrument (therefore
reducing torque and increasing cutting eciency and safety), and reduces
the instrument tip contact and the incidence of procedural errors.
Step back
The step back idea is to enlarge apically rst and then step coronally
by sequentially increasing instrument sizes or taper (aring) for each
instrument of a le series. A direct comparison between crown down and
step back has shown that using crown down will result in less tip contact,
less force, and less torque compared with step back. As a result, crown down
is safer than step back [7]. Nevertheless, step back is essential for dierent
steps of instrumentation.
Apical widening
The apical widening idea simply describes using a series of les in increasing order to enlarge the apex by using all les to the same length. This approach is particularly important for the last steps of apical instrumentation.
Ideal preparation
The ideal preparation form for the hybrid concept takes its pattern from
the denition by Herbert Schilder [8] and is slightly modied: a threedimensional continuously tapering cone in multiple planes with sucient
apical enlargement preserving foramen position and size (modication in
italics).
The dierent steps of the biomechanical instrumentation [9] should be
performed in a crown down manner in the following order: access cavity,
straight line access, working length determination, master apical le (MAF)
size determination, glide path creation, body shaping, and apical preparation (apical pre-enlargement, apical enlargement, apical LightSpeed
instrumentation, apical nishing). The benets of working in this order
include less risk of iatrogen contamination, more visibility and control over
the area of dentinal wall removal, better access for irrigants, and less procedural errors.
For best cutting eciency, the general instrumentation approach preferably should be performed crown down; however, a combination with step
back and apical widening is often needed.
With tapered instruments, taper lock (staying with a constant instrument
taper) should be avoided whenever possible because varying the taper

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H. Walsch / Dent Clin N Am 48 (2004) 183202

during instrumentation will reduce the contact area of the instrument with
the root canal wall and, therefore, reduce the torque load and increase the
cutting eciency and safety.

Dierent canaldierent approach


For all steps of root canal preparation, there is no one perfect system
of NiTi rotary instruments for all cases. Dierent canals require dierent
approaches. Not every clinical situation can be managed with one particular
system, and dierent systems have dierent properties that should be used
where they work best within the hybrid concept. Therefore, an understanding of where each instrument performs its cutting action in the canal
is needed.
A chronologic description of all the steps of biomechanical instrumentation using the hybrid concept is given below.

Straight line access


After achieving an ideal access preparation outline, removing calcications, and gaining access into the root canals, the coronal third of the canals
needs to be straight lined to minimize the coronal aspect of the curvature
(Figs. 3, 4). A straight line form can be gained by removal of the dentinal
overhang in the outer aspect of the orice and coronal third of the canal.
The straight line form eases the penetration of the irrigation solution and
following instruments. It will decrease the coronal interference and,
therefore, increase control over the instruments.
Straight line access can be achieved with GG burs in descending order
from size 4 to 1 or with orice shapers. A GG bur size 1 compares to a le
size 40 to 50, a GG bur 2 to size 60 to 70, a GG bur 3 to size 80 to 90, and
a GG bur 4 to size 100 to 110. This sequence can be repeated, and in cases
with little curvature, 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. In cases with more curvature, more body
shaping needs to be performed with NiTi rotary instruments later on, as
described later. In calcied cases, the GG sequence needs to be reversed,
from size 1 to 4.

Working length
The next step is the working length determination. There are ve methods
available (dierently angulated radiographs, electronic apex locator, tactile
sense, paper point control, patient sensation); a combination of at least the
rst two should be used on a regular basis.

H. Walsch / Dent Clin N Am 48 (2004) 183202

191

Fig. 3. Straight line access in an upper molar. (A) Before straight line access. (B) After straight
line access. (C) After completion of instrumentation; buccal canals.

Master apical le size


The apical canal enlargement to the desired MAF size, shouldamong
other criteriabe based on the original apical canal diameter: the optimal
enlargement of each canal should be calculated. . .based on the initial size of
le 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]. The
apical cross-section of a root canal in most cases, however, is not round in
shape but consists of a minor and a major aspect (minimal and maximal
diameter). In determining the minor initial canal diameter at the working
length, the use of a LightSpeed instrument has been shown by Levin et al
[12] to be more accurate than a K le (one versus three ISO sizes too small,
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 le [13]. Both studies are in agreement that there is a tendency to
underestimate the original apical diameter. Anatomic investigations conrm
that in many cases, the original apical diameter is size 30 or 40 or even larger
[1417]. Moreover, there is currently no way to estimate the major original
apical canal diameter clinically.
It is advisable to determine the minimal apical diameter with a LightSpeed
instrument after determining the working length. Starting from a small
instrument size, by increasing the le size, one will nd the rst smallest

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H. Walsch / Dent Clin N Am 48 (2004) 183202

Fig. 4. Straight line access on radiograph. Dotted lines and arrows indicate areas of dentinal
overhang to be removed.

instrument binding at the working length. From this size, the apex should be
enlarged at least three to four ISO sizes bigger; however, averages cannot
apply in every case. A clinical judgment needs to be made to dene the MAF
size. All information available about the anatomy of the canal system and
the technical diculty of the case should be taken into consideration. The
ideal apical preparation would result in a consistently round form because
this allows for better cleaning of the entire canal wall and better apical seal
[18,19]. In many cases such as ribbon-shaped canals, this goal cannot be
achieved; however, clinicians should try to reach as close as possible to this
goal whenever possible, which often means enlarging the canal wider than
previously thought.

Glide path
Before using any NiTi rotary instruments, a glide path for these
instruments up to ISO size 20 with stainless steel K hand les (0.02 taper)
needs to be created so that the fragile tips of small-sized NiTi rotary
instruments can follow the path without exploring the canal or cutting. Even
light pressure or a small amount of torque would otherwise fracture these
instrument tips.

H. Walsch / Dent Clin N Am 48 (2004) 183202

193

A suitable hand instrumentation technique for stainless steel les smaller


than size 15 is watch-winding and pull, requiring cleaning the les after
each pull. The best technique for sizes 15 to 20 is the balanced force technique [20].

Body shaping
The next step is a fast and eective removal of the coronal and middle
canal third. The classic GT le set (see Fig. 2) has been successfully used for
this purpose in decreasing taper order in a crown down manner. This
sequence can be repeated several times if necessary until working length is
reached. Often, the original apical canal diameter is larger than size 20, so
the resulting canal form is ared, with an apical diameter of at least size 20.
Active instruments such as ProTaper can perform this step even more
eectively. The ProTaper shaping instruments SX, S1, S2 are ideal for this
purpose. They rst shape the canal to a ared form with more taper
coronally than apically, similar to the shape of the Eiel Tower in Paris,
France. Then, the taper is increased gradually deeper down into the canal.
This technique is also considered a crown down approach: the taper is
moved crown down, leaving a canal form that allows ideal access for the
apical preparation.

Apical preparation
Apical preparation consists of four steps (apical pre-enlargement, apical
enlargement, apical LightSpeed preparation, and apical nishing) that are
described in the following sections. All four steps may not be necessary in
each individual case, because dierent canals require dierent approaches.
Apical pre-enlargement
The idea of apical pre-enlargement is to cut quickly and eectively the
apical canal third to a size to which the canal at working length can quickly
and safely be enlarged. In easy cases, this can be done with active instruments that cut aggressively. ProTaper nishing instruments F1 to F3,
for example, will leave an ideal preparation form, provided that F3 reached
the working length. This instrument sequence will move the canal taper even
further apically (crown down). ProTaper plays a major role in this hybrid
concept: a full sequence of these instruments can subsequently perform both
body shaping and apical pre-enlargement with ease.
Only the apical 2 to 3 mm need to be further enlarged. The more dicult
the case (the more severe the curvature or the smaller its radius), the more
the clinician should decide to use passive instruments. In very dicult cases,
NiTi rotary instruments also can be used by hand.

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Table 2
Diameter comparison between the multi-tapered ProTaper F3 instrument and 3 consistently
nickeltitanium instruments with tapers of 2%, 4%, and 6% in size 35
Diameter of ProTaper F3

Diameter of consistently tapered


NiTi instruments in size 35

Distance from tip (mm)

(9%)

(7%)

(6%)

(4%)

(2%)

0
1
2
3
4
5

0.30
0.39
0.48
0.57

0.64
0.71

0.35
0.37
0.39
0.41
0.43
0.46

0.35
0.36
0.38
0.39
0.41
0.42

0.35
0.36
0.36
0.37
0.38
0.39

Apical enlargement
After pre-enlarging the apex safely, it often needs to be enlarged more,
based on the decision of which size MAF should be used for the individual
canal. Apical enlargement can be performed with active or passive tapered
instruments, depending on the diculty of the canal curvature.
Tables 2 through 5 show diameter comparisons at dierent levels from
the tip of the multi-tapered ProTaper F3 instrument and other NiTi rotary
instruments with consistent tapers of 0.06 (6%), 0.04 (4%), and 0.02 (2%).
Table 2 compares an instrument with a tip size of 35, Table 3 with size 40,
Table 4 with size 45, and Table 5 with size 50. Areas in which the
consistently tapered instruments are larger than the ProTaper F3 instrument
are highlighted in gray. Provided that a ProTaper F3 instrument has
reached the working length, it becomes obvious that a size 35 instrument
(regardless of the taper) used after a ProTaper F3 instrument to the same
length in the canal only cuts at the very tip (up to less than 1 mm from the
tip) because at 1 mm from the tip, the size prepared by ProTaper F3 is
already size 39 (see Table 2). Table 5 shows that a size 50 instrument with
a 0.06 taper will cut along the 4 mm from the tip, whereas a size 50
instrument with a 0.02 or 0.04 taper will cut only at the apical 3 mm. The
Table 3
Diameter comparison between the multi-tapered ProTaper F3 instrument and 3 consistently
tapered nickeltitanium instruments with tapers of 2%, 4%, and 6% in size 40
Diameter of ProTaper F3

Diameter of consistently tapered


NiTi instruments in size 40

Distance from tip (mm)

(9%)

(7%)

(6%)

(4%)

(2%)

0
1
2
3
4
5

0.30
0.39
0.48
0.57

0.64
0.71

0.40
0.42
0.45
0.47
0.50
0.52

0.40
0.42
0.43
0.45
0.46
0.48

0.40
0.41
0.42
0.42
0.43
0.44

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Table 4
Diameter comparison between the multi-tapered ProTaper F3 instrument and 3 consistently
tapered nickeltitanium instruments with tapers of 2%, 4%, and 6% in size 45
Diameter of ProTaper F3

Diameter of consistently tapered


NiTi instruments in size 45

Distance from tip (mm)

(9%)

(7%)

(6%)

(4%)

(2%)

0
1
2
3
4
5

0.30
0.39
0.48
0.57

0.64
0.71

0.45
0.48
0.50
0.53
0.56
0.59

0.45
0.47
0.49
0.50
0.52
0.54

0.45
0.46
0.47
0.48
0.49
0.50

idea of this comparison becomes clear: after having reached the working
length with a ProTaper F3 instrument, it is not dicult to enlarge the apex
even wider because other NiTi rotary instruments like FlexMaster or other
active or passive tapered instruments in sizes such as 40 with a 0.06 or 0.04
taper and even size 50 with a 0.02 taper can be used subsequently with
minimal coronal interference, minimal cutting surface, and therefore,
minimal torque load.
Provided in a clinical case that the desired MAF size is 45 and a 0.06
taper should be achieved, according to Table 4, only the apical 3 mm need to
be enlarged. To minimize the torque each instrument has to carry, a size/
taper sequence in the following order can be used: 35/0.04, 35/0.06, 40/0.04,
40/0.06, 45/0.04, and 45/0.06. If all instruments are used to working length,
then this corresponds to the apical widening concept. Accumulation of
dentinal shavings at the apex is almost completely avoided. The number of
instruments for this step of instrumentation seems large, but each instrument cuts only minimally and its cutting action is accomplished quickly
after only one to three rotations. This process can easily be done using the
instruments by hand, and it is safer and faster than changing the les in
a motorized handpiece.
Table 5
Diameter comparison between the multi-tapered ProTaper F3 instrument and 3 consistently
tapered nickeltitanium instruments with tapers of 2%, 4%, and 6% in size 50
Diameter of ProTaper F3

Diameter of consistently tapered


NiTi instruments in size 50

Distance from tip (mm)

(9%)

(7%)

(6%)

(4%)

(2%)

0
1
2
3
4
5

0.30
0.39
0.48
0.57

0.64
0.71

0.50
0.53
0.56
0.59
0.62
0.65

0.50
0.52
0.54
0.56
0.58
0.60

0.50
0.51
0.52
0.53
0.54
0.55

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H. Walsch / Dent Clin N Am 48 (2004) 183202

Fig. 5. Hybrid sequences overview.

The more severe the curvature, the smaller the taper of the apical
preparation should be and the more the clinician should decide to use
passive instruments. At several millimeters from the working length, the
dierence in size between the existing ProTaper preparation and the size of
the instrument used for the apical enlargement becomes so big that this
instrument can slightly straighten in the canal curvature and therefore does
not need to be bent so hard to follow the curvature. In some cases, the
severity of the curvature may not have allowed the use of the same
instrument around the particular curvature without previous apical preenlargement as described earlier.
Apical LightSpeed preparation
This step is necessary when the desired MAF size is bigger than a size that
can be prepared with tapered instruments in a curved canal [21].
The apex will be enlarged to the desired size starting with a LightSpeed
instrument that is one LightSpeed size larger than the last instrument that
previously reached the working length. The instruments are all used to
working length in increasing size order, and no instrument should be left
out. Because the resulting apical canal form is cylindric, a step back is
needed to create a taper in the apical part of the canal. Step back
increments of 0.5 mm for each LightSpeed size will result in a 0.05 taper;
1-mm increments will give a 0.025 taper. The form of this pseudo-taper,
however, leaves steps in the canal wall. The irrigation needle or the gutta
percha cones might not be able to smoothly bypass these steps on the outer
wall of the canal curvature.

H. Walsch / Dent Clin N Am 48 (2004) 183202

197

Fig. 6. (AC) Sample case 1. See text for detail of the case.

Apical nishing
Apical nishing can be performed using the LightSpeed MAF size instrument or another passive instrument in a 0.02 or 0.04 taper and a size that
follows to working length easily. The instrument will be forwarded to
working length in a clockwise rotating or a watch-winding motion one or
two times by hand. This smoothes the steps in the outer wall of the
curvature and merges the step back taper into the more coronally located
taper.
Hybrid sequences overview
The whole idea of the hybrid concept can be condensed to the overview
shown in Fig. 5. The left side represents easy cases. Toward the right side,
the cases become more dicult. The body shaping and apical preenlargement, in most cases, can be managed with ProTaper instruments,
and in extremely dicult cases, with passive instruments. The apical
enlargement according to the diculty of the case can be performed with
active or passive instruments, and if the MAF size demands, then it can be
performed with LightSpeed. The apical nish after LightSpeed step back
can follow by hand with the LightSpeed MAF size or another passive
instrument that can follow to working length without much eort. As new
instruments are developed, they can be integrated into this hybrid concept.

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H. Walsch / Dent Clin N Am 48 (2004) 183202

Fig. 7. (AC) Sample case 2. See text for detail of the case.

Sample cases
Figs. 6 through 10 show several clinical cases in ascending order of
diculty. The protocols of instrumentation used for each case are described
below.
In case 1 (Fig. 6), having a mild curvature, straight line and radicular
access were performed with GG burs in descending order from 4 to 1.
Instrumentation to ProTaper F3 completed body shaping and apical preenlargement. Apical enlargement was done with Flexmaster instruments of
size/taper 35/0.04, 35/0.06, 40/0.04, and 40/0.06. Taper lock was avoided.
Active instruments were used exclusively according to the low-grade
diculty of the case.
Case 2 (Fig. 7) also had a mild curvature. Straight line and radicular
access were performed with GG burs in descending order from 4 to 1. Body
shaping and apical pre-enlargement were managed with ProTaper to F3.
Apical enlargement was performed with passive ProFile instruments. For
the distal canals, ProFile instruments of size/taper 35/0.04, 35/0.06, 40/0.04,
40/0.06, 45/0.04, 50/0.04, and 55/0.04 were used. The isthmus has been
completely opened with ultrasonic instruments and Hedstrom hand instruments. The mesial canals were completed with ProFile instruments of size/
taper 35/0.04, 35/0.06, 40/0.04, and 45/0.04.
Case 3 (Fig. 8) was moderately curved. Straight line and radicular access
were performed with GG burs in the following order: 1 to 3, 4 to 1.

H. Walsch / Dent Clin N Am 48 (2004) 183202

199

Fig. 8. (AD) Sample case 3. See text for detail of the case.

ProTaper was used to F3 for body shaping and apical pre-enlargement.


Because of the degree of the mesial curvature, apical enlargement could not
be performed with tapered instruments. Therefore, LightSpeed instruments
were used for this step: mesial to size 45, distal to size 55. A step back was
performed: distal to size 70, mesial to size 60. A ProFile instrument of size/
taper 45/0.06 was used by hand in a watch-winding motion to smooth the
step back steps.
Case 4 (Fig. 9) represented a severe curvature. After gaining access into
the mesio-buccal canals with small hand instruments and GT les of size/
taper 20/0.10, 20/0.08, and 20/0.06, straight line and radicular access were
achieved with GG burs in the order of 1 to 3, 4 to 1. Body shaping and
apical pre-enlargement in the buccal canals was performed with ProTaper
instruments to F2; F3 went only 3 mm short of working length. The
apex was then enlarged to LightSpeed size 35, step back to size 55, and the
steps were smoothed with a ProFile instrument of size/taper 35/0.04 by
hand.
Case 5 (Fig. 10) had a very large and long palatal canal that was
completely calcied coronally. After gaining access into the canal lumen
with ultrasonic instruments, straight line access and body shaping with GG
burs size 5 to 3 was done to 4 mm short of working length. Apical
enlargement was performed with a ProTaper F3 instrument by hand, which
went passively. Then, LightSpeed was used to size 80, step back to size 90
and 100, and the canal was smoothed with LightSpeed size 80 by hand.

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H. Walsch / Dent Clin N Am 48 (2004) 183202

Fig. 9. (AC) Sample case 4. See text for detail of the case.

Limitations of the hybrid concept


Coronally located canal curvatures, particularly when there is a considerable canal length located apically of the curvature, cannot be managed
properly with tapered NiTi rotaries. NiTi hand les used in a step back
approach or the use of LightSpeed instruments seems to be the best option
for such cases.
Extremely severe curvatures (radius \2 mm) should not be followed with
any engine-driven instruments. NiTi K hand les with 0.02 taper or
LightSpeed instruments should be used, and only by hand.

H. Walsch / Dent Clin N Am 48 (2004) 183202

201

Fig. 10. (A, B) Sample case 5. See text for detail of the case.

In S-shaped curvatures, engine-driven instruments should be used only to


the point where the rst curvature turns into the second one (where the
curvature changes its direction). Beyond that level, hand instrumentation is
recommended.
Ribbon-shaped canals are the classic case for circumferential ling by hand.
NiTi rotary instruments used with a motor can deect at uneven parts of the
canal wall, be pulled away from their paths, and become jammed or separated.
C-shaped canals should only be hand instrumented because of their
unpredictable anatomy.
Apical canal bifurcations often do not allow any straight instrument to
follow into either branch of the furcation. Pre-curving stainless steel les
seems to be the best solution. Never pre-curve NiTi rotary instruments.
Merging canals, like those often found in the mesial roots of mandibular
molars, sometimes do not join at the apex but join more coronally. One of
the two canals will often reach from the orice to the apex (main canal),
whereas the other will meet the rst one in a severe angle (merging canal).
Following the merging canal to working length means forcing the instrument through a kink. With small hand les and tactile sense, the main canal
should be identied and instrumented to working length. Then, the merging
point needs to be identied, and instrumentation of the merging canal
should be performed only to the merging point, followed by recleaning the
main canal to working length.
Summary
Each individual case requires an individual instrumentation approach.
Dierent instruments of dierent NiTi rotary instrument systems and other

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H. Walsch / Dent Clin N Am 48 (2004) 183202

instrument systems can be combined in a hybrid concept, 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.
Depending on the desired MAF size and the diculty of the case, dierent
hybrid instrumentation sequences can be used, with some limitations.

References
[1] Knowles KL, Ibarrola JL, Christiansen RK. Assessing apical deformation and transportation following the use of LightSpeed root canal instruments. Int Endod J 1996;29:
1137.
[2] Thomson SA, Dummer PMH. Shaping ability of LightSpeed rotary nickel-titanium
instruments in simulated root canals. Part 2. J Endod 1997;23:7427.
[3] Vulcain J, Calas P. The three wave concept of HERO 642. Endod Pract 1999;2:2031.
[4] Gabel WP, Hoen M, Steiman HR, Pink FE, Dietz R. Eect of rotational speed on nickeltitanium le distortion. J Endod 1999;25:7524.
[5] Dietz DB, Di Fiore PM, Bahcall JK, Lautenschlager EP. Eect of rotational speed on the
breakage of nickel-titanium rotary les. J Endod 2000;26:6871.
[6] Baumann M, Roth A. Eect of experience on quality of canal preparation with nickeltitanium les. Oral Surg Oral Med Oral Pathol 1999;88:7148.
[7] Blum JY, Machtou P, Micallef JP. Location of contact areas on rotary ProFile instruments
in relationship to the forces developed during mechanical preparation of extracted teeth.
Int Endod J 1999;32:10814.
[8] Schilder H. Cleaning and shaping the root canal. Dent Clin N Am 1974;18:26996.
[9] Moodnik RM, Dorn SO, Feldman MJ, Levey M, Borden BG. Ecacy of biomechanical
instrumentation: a scanning electron microscopic study. J Endod 1976;2:2616.
[10] Weine FS. Intracanal treatment procedures, basic and advanced topics. 5th edition. St.
Louis (MO): C.V. Mosby; 1996.
[11] Grossman LI. Endodontic practice. 8th edition. Philadelphia: Lea & Febinger Co.; 1974.
[12] Levin JA, Liu DT, Jou YT. The accuracy of two clinical techniques to determine the size of
the apical foramen [abstract]. J Endod 1999;25:294.
[13] Wu MK, Barkis D, Roris A, Wesselink PR. Does the rst le to bind correspond to the
diameter of the canal in the apical region? Int Endod J 2002;35:2649.
[14] Kuttler Y. Microscopic investigation or root apexes. J Am Dent Assoc 1955;50:54452.
[15] Kerekes K, Tronstad L. Morphometric observations on the root canals of human anterior
teeth. J Endod 1977;3:249.
[16] Kerekes K, Tronstad L. Morphometric observations on the root canals of human
premolars. J Endod 1977;3:749.
[17] Kerekes K, Tronstad L. Morphometric observations on the root canals of human molars.
J Endod 1977;3:1148.
[18] Luks S. Guttapercha versus silver points in the practice of endodontics. N Y State Dent
J 1965;31:34150.
[19] Hwang HK, Jou YT, Kim S. Sealing ability of isthmuses by dierent obturation techniques
[abstract]. J Endod 1998;24:283.
[20] Roane JB, Sabala CL, Duncanson MG. The balanced force concept for instrumentation in
curved canals. J Endod 1985;11:20311.
[21] Hulsmann M. Wurzelkanalaufbereitung mit Nickel-Titan-Instrumenten. Kombinierte
Technik. 1st edition. Berlin: Quintessenz Verlags-GmbH; 2002.

Dent Clin N Am 48 (2004) 203215

Obturation of the root canal system


Samuel I. Kratchman, DMD
Department of Endodontics, School of Dental Medicine, University of Pennsylvania,
240 South 40th Street, Philadelphia, PA 19104-6030, USA

There have been numerous articles written on instrumentation techniques


using the dierent rotary nickeltitanium les on the market. Practitioners
tend to develop a system that works best for them. Often, this is a hybrid of
several techniques discussed in various articles [1]. After creating clean,
tapered canals, clinicians need to adequately obturate the root canal system.
This is best accomplished by using warm gutta percha, with the System B
heat transfer system (Sybron Endodontics, Orange, California) (Fig. 1), the
new S-Kondensers (Obtura/Spartan, Fenton, Missouri) (Fig. 2), and the
Obtura II (Obtura/Spartan) (Fig. 3).
Several years ago, the transition in endodontics took place from stainless
steel hand les to nickeltitanium rotary les. Obturation often was still
performed with cold lateral condensation of gutta percha, taking twice as
long as the newer, warm techniques due to the taper created in the canals.
Then, many clinicians made the transition to warm gutta percha, and not
only did the radiographic appearance improve but it was also more time
ecient [2].
Canals are commonly nished with a 0.04 or 0.06 taper rotary le. This
information is not relevant for this article other than when choosing the
proper tip for the System B unit (Fig. 4). The 0.06 taper most closely
resembles the medium-sized tip on the System B, and if the preparation is
nished with 0.04 taper rotary les instead, then the medium/ne System B
tip would be indicated. 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 t
approximately 4 to 5 mm from the working length. This technique allows
the proper removal of the bulk of gutta percha from the canal while
transferring heat to the 4- to 5-mm apical plug. This proper removal is
accomplished by activating the System B coil with a nger 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.com
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.004

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S.I. Kratchman / Dent Clin N Am 48 (2004) 203215

Fig. 1. System B unit from Sybron Endodontics.

of the working length. The nger is then removed from the coil and the
System B tip is allowed to cool down. Because the tips are hollow, they heat
up almost instantaneously to the set temperature. After allowing the tip to
cool for 10 seconds while still in the canal, the coil is engaged for a split
second while pushing apically, and then the tip is withdrawn from the canal
with the now-severed gutta percha wrapped around the tip. There will be
a learning period when a clinician new to the technique pulls out the entire
gutta percha cone from the canal instead of leaving behind that apical plug.
When this happens, it means there was not adequate tug back of the master
cone and a new cone will need to be retted [3]. Nonstandardized medium
gutta percha cones and a gutta gauge can be used to customize those master

Fig. 2. New set of three S-Kondensers (Obtura/Spartan).

S.I. Kratchman / Dent Clin N Am 48 (2004) 203215

205

Fig. 3. The Obtura II unit comes complete with instructional video and plastic practice blocks.

Fig. 4. The medium System B tip compares closely to a medium gutta percha cone and a 0.06
taper rotary nickeltitanium le.

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S.I. Kratchman / Dent Clin N Am 48 (2004) 203215

Fig. 5. Gutta gauge, used to customize the gutta percha cone.

cones (Fig. 5). The medium gutta percha cones most closely resemble the
0.06 taper created in the canals, but 0.04 and 0.06 taper standardized gutta
percha can now be purchased.
Because of the heat transfer process of the System B, there is now
a softened apical plug of gutta percha in the canal. The next step is to

S.I. Kratchman / Dent Clin N Am 48 (2004) 203215

207

Fig. 6. Apical plug of gutta percha remains in canal and can now be packed down.

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

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S.I. Kratchman / Dent Clin N Am 48 (2004) 203215

Fig. 7. Notches at 5-mm intervals on the nickeltitanium end of the S-Kondensers.

Obtura II unit is nicely packaged with an instructional video and a plastic


block with which to practice. The tips come in 23 gauge and a thinner 25
gauge. If you choose to use the 25-gauge tip, you must use the gutta percha
pellets designed for this tip, which soften at a lower temperature. 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, 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. 10 and 11). Now place the
wrench back over the tip and quarter turn counter-clockwise, loosening the
tip slightly. This will allow you to rotate the tip, whether you are obturating
a lower tooth or an upper tooth, without it loosening too much that gutta

Fig. 8. Indentation in handle of S-Kondenser for nger rest during condensation.

S.I. Kratchman / Dent Clin N Am 48 (2004) 203215

Fig. 9. Obtura II unit ready to go.

Fig. 10. Installation of needle.

209

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S.I. Kratchman / Dent Clin N Am 48 (2004) 203215

Fig. 11. Tip-bending instrument.

Fig. 12. Void in gutta percha ling.

S.I. Kratchman / Dent Clin N Am 48 (2004) 203215

211

percha would extrude out the sides. You must place the Obtura II tip in the
canal and make contact with the apical plug of gutta percha before back
lling. Once the tip is in contact with the now cooled apical gutta percha
plug, let it remain there for three seconds, re-heating that apical plug. This
will prevent voids from occurring between the apical gutta percha and the
remainder of the lling (Fig. 12). If you hear a crackling noise while injecting
the gutta percha, it is an air pocket, and will not aect the ll, as long as you
continue to press the trigger, lling the canal. You may back ll in one
motion, not segmentally, and after completing the back lling of each canal,
backpack with the stainless steel end of the S-Kondenser. The root canal is
now complete.
Most so-called problems with obturation are actually problems with
ones instrumentation. The obturation is in essence an impression of what
the canal looks like after it has been instrumented. If one is not happy with
the appearance of the nal x-ray, you are actually criticizing the
instrumentation/aring of the canals. If the master gutta percha cone does
not seat all the way to the desired working length, you must go back with
a le to make sure there is no debris in the canal and that the aring is
adequate. If the master cone goes beyond the apex (Fig. 13), you must

Fig. 13. Gutta percha extruding through apex.

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Fig. 14. (A) Preoperative radiograph of retreatment of maxillary rst molar. (Courtesy Kevin
Edwards, DDS, Portland, Oregon) (B) Postoperative radiograph.

attempt to achieve an apical stop with further instrumentation at a shorter


working length.
There are some cases where the aforementioned technique of obturation
makes an impossible case approachable. Examine the pre-operative x-ray
of a rnaxillary molar with previous root canal therapy (Fig. 14). Note that
the periapical lesion associated with the palatal root is not only at the
radiographic apex, but also toward the side of the apex. This maxillary
molar had an apical bifurcation of its palatal canal, and instead of burning
out the gutta percha with the System B to within 4-5 mm of the working
length, this time we went down to within 2mm of the working length,
making room to place the second master cone to the desired length. That
second master cone is then burned out to within 4-5 mm, and the entire
canal is back-lled in one motion with the Obtura II. This case could not
have been obturated using a cold lateral gutta percha technique, due to an

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213

Fig. 15. (A) Preoperative radiograph of mandibular bicuspid with trifurcation of canals.
(Courtesy Kevin Edwards, DDS, Portland, Oregon) (B) Postoperative radiograph.

Fig. 16. Four-canal maxillary molar.

Fig. 17. Maxillary molar with long but gentle curvature of MB root.

Fig. 18. (A,B) Mandibular molars with lateral canals lled in apical third of distal root.

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215

inability to properly seat two master cones side by side in the palatal
canal.
Another case where the warm vertical technique was necessary was
a mandibular bicuspid with a trifurcation of its canal (Fig. 15). Three separate
master cones were used, with each cone being burned out apically to the
trifurcation, allowing room for the next master cone to be seated. After the
three master cones were placed and the System B used to leave three apical
plugs of gutta percha, the whole system was back lled with the Obtura II.
A few more cases such as this maxillary molar with four canals (Fig. 16)
and another maxillary molar with a long gentle curve (Fig. 17), depict the
results obtainable with the above described obturation technique. These two
mandibular molars (Fig. 18) have small lateral canals in the apical third, and
with the warm vertical technique using a thermoplasticized (semi-solid) form
of gutta percha, you will see a higher incidence of lling such lateral canals.
There are many approaches to solving a problem. Similarly, in endodontics, there are several ways to instrument and to obturate the root canals.
Practitioners often develop their own hybrid technique, using ideas
from several colleagues. The purpose of this chapter was to share a technique
of obturation, with the hope that others may incorporate some aspects into
their own style.
References
[1] Guess G, Edwards K Yang ML, Iqbal M, Kim S. Analysis of continuous S-Kondensers
wave obturaton using a single-cone and hybrid technique. J Endodon 2003;29:50912.
[2] Schilder H. Filling root canals in three dimensions. Dent Clin N Am 1967;1:72344.
[3] Weller RN, Kimbrough WF, Anderson RW. A comparison of thermoplastic obturation
techniques: adaptation to the canal walls. J Endodon 1997;23:7036.
[4] Buchanan LS. Continuous wave of condensation technique. Endodon Pract 1998;1:718.

Dent Clin N Am 48 (2004) 217264

MicroSeal systems and modied technique


Francesco Maggiore, DDS
Department of Endodontics, School of Dental Medicine, University of Pennsylvania,
240 South 40th Street, Philadelphia, PA 19104-6030, USA

Proper obturation of the root canal system is an essential nal step of


endodontic therapy. In fact, the endodontic lling has the primary goals of
keeping clean the environment achieved by the biomechanical instrumentation, providing a hermetic apical and coronal seal, and eventually obliterating within the obturation material any remnants or debris that the
endodontic instruments or solvents are not able to eliminate [13].
Technically speaking, the aforementioned objectives can be obtained by
an endodontic lling that is able to penetrate the entire root canal system,
extend as close as possible to the cementodentinal junction, and have an
adequate density necessary for the operator to radiographically evaluate the
endodontic procedure [4,5].
The concept that a successful obturation depends very much on proper
cleaning and shaping procedures is well accepted by practitioners. Thus, 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.
A key step during the biomechanical instrumentation and for the
obturation is the access cavity preparation. 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 orices but conservative enough to prevent any
unnecessary loss of coronal dentin. Also, 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. Although additional removal of
coronal dentin during the access preparation would facilitate ample access,
it would also weaken the root walls and possibly predispose the root to
lateral or strip perforations and root fractures during post placement [6].
Nevertheless, 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]. Thus, in situations in which
E-mail address: fmaggiore@hotmail.com
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.11.005

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Fig. 1. Components of the MicroSeal system (SybronEndo, Orange, California).

Fig. 2. MicroSeal nger spreaders (size/taper): 20/0.02 (top), 25/0.02 (middle), 25/0.04 (bottom)
(SybronEndo).

this placement is not possible because of a canals narrow dimension,


a conservative preparation, or a curved canal, 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]. It is obvious that this enlargement is not
biologically dictated; rather, it is due to the technical limitation of the
obturation method.
One of the obturation techniques more likely suitable for the above cases
is the MicroSeal obturation system (SybronEndo, Orange, California)

Fig. 3. MicroSeal engine spreaders (size/taper): 25/0.04 (top), 25/0.02 (middle), 20/0.02 (bottom)
(SybronEndo).

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219

Fig. 4. MicroSeal condenser size 25, 0.04 taper (SybronEndo).

Fig. 5. MicroSeal condenser size 25, 0.04 taper. Measurement of the angle between the blades
and the axis of the instrument (SybronEndo).

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Fig. 6. Vertical and lateral forces generated by the MicroSeal condenser (SybronEndo).

Fig. 7. MicroSeal gutta percha cones (size/taper): 25/0.04 (far right), 25/0.02 (middle right), 30/
0.02 (middle left), 35/0.02 (far left) (SybronEndo).

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221

Fig. 8. MicroSeal gutta percha heater (SybronEndo).

because it is able to preserve a conservative preparation and provide an


adequate penetration by the obturation instruments in the apical third. In
this article, dierent aspects of this technique are discussed.
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 rst thermomechanical compaction technique was
introduced by Dr. J.T. McSpadden in 1979 (personal communication, 1979).
The MicroSeal system consists of a series of instruments: the nickel
titanium (NiTi) spreader, the NiTi condenser, the gutta percha heater, the
gutta percha syringe, and a special formulation of gutta percha available in
cones or in cartridges, called low-fusing gutta percha or ultralow-fusing
gutta percha, respectively (Fig. 1).
MicroSeal nickeltitanium nger and engine spreader
The MicroSeal system provides nger and engine NiTi spreaders. The
nger spreaders are available in 0.02 taper in size 20, 25, 30 and in 0.04 taper
in size 25 (Fig. 2). They are designed to be used with a continuous rotational
motion. The engine spreaders are mounted on a 1:16 reduction handpiece
and used at 300 rpm (Fig. 3).
The MicroSeal technique suggests the use of one master cone at the
working length. After placement of the master cone at the working length,
the spreader compacts the gutta percha cone in the apical third and because
of its high exibility, it can reach the proper depth in the majority of the
clinical situations [9].

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Fig. 9. Radiograph conrming the length of the master cone (MicroSeal, SybronEndo).

MicroSeal condenser
Particularly interesting is the MicroSeal condenser (Fig. 4). This
instrument is made of NiTi, has a reverse helix design, and is available
in 0.02 taper in sizes 25 to 60 and in 0.04 taper in size 25. The condenser is

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223

Fig. 10. MicroSeal spreader reaches the proper length alongside of the master cone
(SybronEndo).

designed to be used on a 1:1 electric handpiece between 5000 and 7000


rpm.
During its rotation into the root canal, the condenser has the primary
goal of generating heat by friction to plasticize the gutta percha cone. Also,
the condenser creates centrifuge forces able to press the warm gutta percha

Fig. 11. MicroSeal condenser coated with warm gutta percha from the cartridge (SybronEndo).

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 12. MicroSeal condenser carries warm gutta percha into the canal (SybronEndo).

into all the spaces within the root canal. Because it is made of NiTi, it is
highly exible and can reach the apical 2 to 3 mm in most cases.
On careful inspection of the angle between the reverse blades of the
condenser and the axis of the instrument, a decrease in amplitude from

Fig. 13. Tooth No. 19. Apical hook in the distal root.

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225

Fig. 14. (A) Preoperative radiograph for tooth No. 23 showing an apical bifurcation. The tooth
has been prosthetically prepared before the root canal. (B) Postoperative radiograph for tooth
No. 23. Note the small access cavity to preserve the prosthetic preparation and the management
of the apical bifurcation.

the handle to the tip can be noticed; that is, the angle between the blade and
the shaft is more open in the coronal part and gradually becomes more closed
in the apical part. The authors measurements, using Cad-Cam software,
provided an angle varying from 60 to 30 (Fig. 5). This assessment has a very
important clinical implication. In fact, the forces generated by the rotating
condenser are directed apically mostly in the coronal part of the instrument
and laterally at the tip level. This unique design is most likely thought to
prevent the possibility of extrusion of the gutta percha beyond the apical
constriction. Also, for these reasons, the condenser can be considered to act
as a plugger in the coronal part of the root canal and as a spreader in the
apical region, generating vertical and lateral forces selectively (Fig. 6).

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Fig. 14 (continued )

MicroSeal gutta percha cones


According to the manufacturer, the MicroSeal technique requires the use
of one master cone at the working length. MicroSeal gutta percha cones are
available in 0.02 taper in sizes 25 to 60 and in 0.04 taper in size 25 (Fig. 7).
The MicroSeal gutta percha cones are made of low-fusing gutta percha,
advertised to be alpha (a) gutta percha at room temperature.
Depending on the temperature, gutta percha is available in two dierent
crystalline forms: the beta (b) phase (37 ) and the alpha (a) phase (42 44 ).
The b-phase gutta percha is the commonly found gutta percha at room
temperature and consists of a high molecular weight polymer. 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

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227

Fig. 15. Spreader D11T (top); spreader D11 (bottom).

breakage of the chemical links of the polymer. Conversely, cooling of the aphase gutta percha will produce b-phase gutta percha, and shrinkage occurs
during this process. Therefore, to compensate for the undesirable shrinkage
of the gutta percha for obturation methods using warm gutta percha, it has
been suggested to compact the material while it is cooling with the use of
a plugger [10].

Fig. 16. Apical foramen with oval shape.

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 17. Use of accessory cones to create an apical stop for canals with oval foramen.

In the MicroSeal system, the cones are made of a-phase gutta percha at
room temperature. In this way, only minimal shrinkage takes place during
the cooling phase.
For the same reason, the gutta percha cartridges consist of ultralowfusing gutta percha. For infection control purposes, the gutta percha
cartridges are made for single-patient use only.

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229

Fig. 18. Radiographic comparison of gutta percha cones size 30, 0.02 taper from the following
brands: Hygenic ( far left), Caulk Densply ISO color (middle left), Caulk Densply ISO noncolor
(middle right), and MicroSeal ( far right).

Fig. 19. Gutta percha cones tested in the preclinical study: Hygenic, Caulk Densply ISO color,
Caulk Densply ISO noncolor, and MicroSeal.

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Fig. 20. Radiographic comparison of gutta percha cones size 30, 0.02 taper from Caulk
Densply ISO noncolor (left) and MicroSeal (right).

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231

Fig. 21. Gutta percha cones from Caulk Densply ISO noncolor used in the preclinical test.

MicroSeal gutta percha heater


To warm the gutta percha in the cartridge, the MicroSeal heater can be
used (Fig. 8). This machine is very easy to handle and after the heater is
turned on, the working temperature is reached within 45 seconds. As soon
as the gutta percha in the cartridge becomes plasticized, it is ready to be
used.

Description of the technique


When the canal is ready to be lled, the selection of the master cone is the
rst step of the procedure. Proper tug back 0.5 to 1 mm short of the working
length is the criteria for the selection of the master cone. According to the
manufacturer, large canals require a 0.04 taper master cone, whereas the
0.02 taper is indicated for narrow canals.
It is advisable to conrm the length of the master cone radiographically
(Fig. 9).

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Fig. 22. Group 1, n 8. Radiographs in clinical (A) and proximal (B) view. Cross-sections at
the 1 mm (C), 5 mm (D), and 7 mm (E) levels.

After dipping the tip of the selected master cone into endodontic sealer, it
is introduced into the canal. The NiTi MicroSeal spreader is advanced to
within 1 to 2 mm from the working length and is rotated (Fig. 10). The
spreader is then removed from the canal; space has been created between the
master cone and the canal walls.
Next, the gutta percha cartridge is heated and the condenser is
introduced into the cartridge and gently removed to cover 5 to 6 mm of
the instrument with warm gutta percha (Fig. 11). The coated condenser
can now be introduced into the canal space created by the spreader
(Fig. 12).

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233

Fig. 22 (continued )

Generally, it is advisable to select a 0.04 taper condenser when a 0.02


taper master cone has been used and to select a 0.02 taper condenser when
a 0.04 taper master cone has been used. The selection of the condenser
strictly depends on the clinical situation.
It is important to place the condenser as close as possible to the
working length and not to rotate the instrument while inserting. After it is
seated, the rotation of the condenser can begin. In the very rst moment of
the spin, the generated force promotes a tendency to withdraw the
condenser from the canal. This force has to be countered by rmly keeping

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 22 (continued )

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235

Fig. 22 (continued )

the instrument in place for 1 or 2 seconds. The condenser is then removed


while rotating with a gentle stroking motion against the canal walls. The
whole procedure requires no more then 6 seconds. If the rst spin does
not ll the canal completely, then the condenser can be coated with new
gutta percha and a second spin can carry additional gutta percha into the
canal.

Modications
The technique just described is the one recommended by the manufacturer. To improve some of the aspects of the technique, the following
suggestions are made by the author.
First, the use of the NiTi spreader is of great advantage, especially in the
case of curved canals, because it guaranties that the instrument reaches the
proper depth of 1 mm from the working length [9,11]. Alternately, in certain
clinical circumstances, as with a sharp apical hook (Fig. 13), the NiTi
spreader can be bent under pressure and may not transmit its compacting
force to the gutta percha cone. Also, there are root canal anatomies such as
apical bifurcations (Fig. 14) that require management by a prebent spreader,

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 23. Group 2, n = 2. Radiographs in clinical (A) and proximal (B) view. Cross-sections at
the 1 mm (C), 4 mm (D), and 5 mm (E) levels.

and the NiTi spreader cannot be precurved [12]. Thus, the use of the
stainless steel spreader D11T can replace the NiTi nger spreader for the
apical compaction of the master cone where indicated (Fig. 15). In addition
to the apical compaction of the master cone, the author nds the use of

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237

Fig. 23 (continued )

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

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 23 (continued )

completely seal the apex. In these situations, the apical foramen is oval in
shape (Fig. 16) or is ribbon shaped due to the conuence of two canals in the
same apical exit [13]. In such situations, in addition to the master cone, the
use of one or two accessory cones (generally 0.02 taper, size 25) may provide
a more secure apical stop against which the rotating condenser can be safely
pushed (Fig. 17). In fact, the use of one master cone in all cases could result
in some undesired overlling or underlling.

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239

Fig. 23 (continued )

Third, according to the manufacturer, the selected master cone can be


a 0.04 taper or a 0.02 taper. Other than the fact that the 0.04 taper gutta
percha cones are available only in size 25with the obvious limitation that
this representsthe 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

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 23 (continued )

can achieve this result more predictably. Also, if one considers that the use
of one or two accessory cones in addition to the master cone is frequently
indicated, the selection of a 0.04 taper master cone would risk creating a bulk
of gutta percha at the orice level. This bulk would interfere with further
insertion of the condenser coated with warm gutta percha. Thus, the 0.02
taper master cone is the one more likely indicated in the majority of the
cases.
A fourth consideration is the use of the plugger at the end of each
compaction. It is true that the ultralow-ow gutta percha from the
MicroSeal system undergoes less shrinkage, but it is also true that after the

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241

Fig. 24. Group 3, n = 1. Radiographs in clinical (A) and proximal (B) view. Cross-sections at
the 1 mm (C), 2 mm (D), 4 mm (E), 5 mm (F), 6 mm (G), and 6.5 mm (H) levels.

use of the condenser, an amorphous mass of gutta percha lls the canal.
To better adapt the melted lling material to the canal walls, the use of the
plugger is of great benet. The author believes that the obturation does not
end with the rotation of the condenser; the coronal compaction using

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 24 (continued )

a plugger of proper size greatly increases the adaptation of the gutta percha
to the root canal system, prevents formation of voids, and ultimately
provides a more dense and homogeneous obturation.
Fifth, one of the main dierences between the MicroSeal gutta percha
cones and other brands of gutta percha cones is the radiopacity. The author
compared the radiopacity of the MicroSeal gutta percha cone with other
gutta percha cones on the market. The MicroSeal gutta percha cones appear
to be less radiopaque (Fig. 18), which may present a disadvantage because
the evaluation of the root canal lling is clinically done on the basis of its
radiographic density [4].

F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 24 (continued )

243

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 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. In a preliminary stage of the
study on extracted teeth, dierent brands of gutta percha cones were
substituted for the MicroSeal cones using the MicroSeal technique.
Gutta percha cones (Hygenic, Caulk Densply International Standards
Organization [ISO] noncolor, Caulk Densply ISO color, and MicroSeal)
were tested (Fig. 19). Among the dierent brands, the cones manufactured
by Caulk Densply (ISO noncolor) were the most similar to the MicroSeal
cones in handling and obturation characteristics. They also showed a higher
radiographic density (Fig. 20). Therefore, the author decided to use the
MicroSeal gutta percha cones and the Caulk Densply (ISO noncolor) gutta
percha cones in the preclinical test (Fig. 21).
In the preclinical study, an interesting observation was that the ISO
color and the ISO noncolor gutta percha cones by Caulk Densply,
despite having the same manufacturer, showed a very dierent clinical
behavior.

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245

Fig. 25. Group 3, n 6. Radiographs in clinical (A) and proximal (B) view. Cross-sections at
the 1 mm (C), 3 mm (D), and 5 mm (E) levels.

Preclinical test
Sixteen straight single-rooted teeth were divided into four groups of 4
teeth each, with each group consisting of two narrow canals and two large
canals. All canals were instrumented using the same instrumentation

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 25 (continued )

technique. After access was made, the prearing was accomplished using
GatesGlidden instruments in sizes 2, 3, and 4. The canals were prepared
using the Proles 0.06 taper. Canals were prepared up to size 35 or 45
depending on the initial apical size and were irrigated with sodium
hypochlorite and EDTA, alternating after each instrument. For the

F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 25 (continued )

247

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 25 (continued )

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

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249

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

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

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 26 (continued )

radiographic density, and (4) ability of the gutta percha to ll irregularities


and lateral canals.
Each category was scored as poor, acceptable, good, or very good. Three
dierent 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 lling 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).

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251

Fig. 26 (continued )

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

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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 dierence in the handling of the MicroSeal or
Caulk-Densply gutta percha.

F. Maggiore / Dent Clin N Am 48 (2004) 217264

253

Fig. 26 (continued )

 The MicroSeal technique using MicroSeal or Caulk-Densply gutta


percha cones proved very eective for obturating lateral canals and
irregularities.

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

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 26 (continued )

Caulk-Densply gutta percha cones. They melt at the same rpm of the condenser after the instrument, coated with warm gutta percha, is introduced
into the canal. The cones, when melted, provide gutta percha that is homogeneously integrated with the MicroSeal gutta percha from the cartridge.
The only dierence appears to be the slightly better radiopacity of the
Caulk-Dentsply cones compared with the MicroSeal cones.

F. Maggiore / Dent Clin N Am 48 (2004) 217264

255

Fig. 27. MicroSeal condenser undergoing very high torsional stress before reaching the
breaking point (SybronEndo).

The cones from Hygenic and from Caulk Densply (ISO color) had very
dierent behavior compared with the MicroSeal and Caulk Densply ISO
noncolor cones in this preclinical study. In fact, the Hygenic cones and
the Caulk Densply ISO color cones seemed to be more elastic and
required a higher speed and more time for the condenser to start the

Fig. 28. Cross-section showing a fragment of MicroSeal condenser incorporated into the lling
material. (Courtesy of Dr. SH Baek, South Korea.)

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

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

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

F. Maggiore / Dent Clin N Am 48 (2004) 217264

257

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

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

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.

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 32 (continued )

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

F. Maggiore / Dent Clin N Am 48 (2004) 217264

261

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

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 signicant 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

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

Fig. 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.
In conclusion, the MicroSeal technique together with the modications
discussed in this article may be a very important tool in the hands of the
endodontist. Knowledge of the techniques 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.

Clinical cases
The clinical cases presented in Figs. 29 through 33 were performed using
Caulk-Densply ISO noncolor gutta percha master and accessory cones.

Fig. 33 (continued )

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F. Maggiore / Dent Clin N Am 48 (2004) 217264

References
[1] Naidorf IJ. Clinical microbiology in endodontics. Dent Clin N Am 1974;18:32944.
[2] Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors aecting the long-term results of
endodontic treatment. J Endod 1990;16:498.
[3] Gutmann JL. Clinical, radiographic and histologic perspectives on success and failure in
endodontics. Dent Clin N Am 1992;36:379.
[4] American Association of Endodontists. Appropriateness of care and quality assurance
guidelines. Chicago: American Association of Endodontists; 1994.
[5] Kersten HW, Wesselink PR, Thoden van Velzen SK. The diagnostic reliability of the
buccal radiograph after root canal lling. Int Endod J 1987;20:20.
[6] Gutmann JL. The dentin-root complex: anatomic and biologic considerations in restoring
endodontically treated teeth. J Prosthet Dent 1992;67:458.
[7] Allison DA, Weber CR, Walton RE. The inuence of the method of canal preparation on
the quality of apical and coronal obturation. J Endod 1979;5:298.
[8] Gutmann JL, Hovland EJ. Problems in root canal obturation. In: Gutmann JL, Dumsha
TC, Lovdahl PE, Hovland EJ, editors. Problem solving in endodontics. 3rd edition.
St Louis (MO): Mosby; 1997. p. 12355.
[9] Berry KA, Primack PD, Loushine RJ. Nickel-titanium versus stainless steel nger
spreaders in curved canals. J Endod 1995;21:221.
[10] Goodman A, Schilder H, Aldrich W. The thermomechanical properties of gutta-percha. II.
The history and molecular structure of gutta-percha. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1974;37:954.
[11] Speier MB, Glickman GN. Volumetric and densitometric comparison between nickel
titanium and stainless steel condensation. J Endod 1996;22:195.
[12] Gutmann JL, Witherspoon DE. Obturation of the cleaned and shaped root canal system.
In: Cohen S, Burns RC, editors. Pathways of the pulp. 7th edition. St. Louis (MO): Mosby;
1998. p. 258361.
[13] Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg 1984;58:589.

Dent Clin N Am 48 (2004) 265289

Conventional endodontic failure


and retreatment
Ralan Wong, DDS, MSa,b,*
a

Department of Endodontics, School of Dentistry, University of the Pacic,


2155 Webster Street, San Francisco, CA 94115, USA
b
Private Practice, San Francisco Endodontics, 500 Spruce Street #204,
San Francisco, CA 94118, USA

Technologic advancements in dentistry have vastly improved the quality


of care provided to the general population. These advancements, in
conjunction with increased dental patient education and awareness, have
helped to promote the view that the dentition should remain throughout
peoples lives. As the life span of the population increases, the need to
maintain a patients dentition for a longer period of time has led to a barrage
of advanced procedures that were nonexistent years ago. As a result, the
need for performing conventional root canal therapy also has increased
dramatically. A survey performed by the American Dental Association
stated that approximately 2.5 million endodontic cases were treated in 1960
[1]. Current studies estimate that the number of endodontic cases treated
annually ranges from 24 to 50 million [14]. This is a dramatic increase.
Ruddle [5] described this vast increase in endodontics as the good news
bad news dilemma. The good news is that hundreds of millions of
teeth are salvaged through the combination of endodontics, periodontics,
and restorative dentistry. The bad news is that tens of millions of
endodontically treated teeth are failing each year for a variety of reasons
[5,6]. For example, the success rate for conventional-treated teeth is 85% to
90%; this still leaves a failure rate of 10% to 15%. In accordance with the
studies mentioned above [16], a 10% failure rate would result in the failure
of at least 2.4 million cases. Therefore, the future of endodontics will include
dealing with the retreatment of its failures.

* Private Practice, San Francisco Endodontics, 500 Spruce Street #204, San Francisco,
CA 94118.
E-mail address: witewong@hotmail.com
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.10.002

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R. Wong / Dent Clin N Am 48 (2004) 265289

Factors for failures


Not all conventional root canal treatments are successful. There have
been many articles published [731] that provide a range of success
anywhere from 53% to 95%. There are many reasons for the wide variety of
outcomes. Several aspects can be attributed to the way in which endodontic
successes and failures are reported. Some important factors are the
frequency of recall evaluations, operators ability, tooth selection, number
of cases evaluated, patients subjective response to and compliance with
treatment, method of determining failures, and subjective interpretation of
the results. There are approximately 25 potential factors reported in the
literature that inuence the outcome of conventional endodontic therapy
(Table 1) [27]. Throughout the literature, these factors have been evaluated
and reviewed with both agreement and disagreement as to their inuence on
endodontic success rates. There are some factors, however, that consistently
are reported to have an inuence on success or failure. These factors are as
follows: the extension of the lling material, quality of the obturation, case
Table 1
Potential factors inuencing success of endodontic therapy
Factors

Eect or success

No eect on success

Presence of apical pathosis


Extension of lling 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 lling used
Number of treatments
Postoperative restoration
Intracanal medicament
Preoperative pain
Postoperative pain
Apical resorption
Length of time for treatment
Procedural periapical inoculation
Patients 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.
Data from Refs. [731].

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267

selection, root canal system anatomy, inadequacy of cleaning and shaping,


presence of periapical pathosis, iatrogenic procedural errors, and length of
the observation period [5,6,16,32]. Presently, the belief is that the most
important cause of failure is recontamination of the entire root canal system
resulting from coronal bacterial leakage [26,3335]. No correlation of the
maxilla versus the mandible exists, nor does age or gender appear to play
a role in the pathogenesis of endodontic failures.

Conventional retreatment versus microsugery


Endodontic failures are associated most often with periapical pathosis
and pain. The decision to perform nonsurgical conventional retreatment,
microsurgical endodontics, or even extraction and placement of an implant
must be assessed carefully. There have been considerable improvements in
endodontic microsurgery techniques that allow for the once-hopeless tooth
to be salvaged [5,6,8]. These techniques and procedures are still limited by
the amount of pulp tissue, bacteria, and any other irritants that can be
removed successfully [5]. Therefore, a diligent examination of the suspected
tooth must be performed to gather information so that the proper treatment
can be rendered. For example, restorability, coronal leakage, missed canals,
fractures, iatrogenic procedural errors, ability of the operator, type of lling
material, ability to gain access to the lling material and the terminus of the
root canal system, quality and extent of the obturation, patients desires,
and cost eectiveness must be considered before treatment planning.
Consultation with the appropriate specialist, or team of specialists, to
determine feasibility of treatment, prognosis, and cost eectiveness is of
utmost importance for the clinician. Fig. 1 depicts a brief rationale strategy
for deciding whether conventional nonsurgical retreatment or endodontic
microsurgery is the best option.

Endodontic retreatment: case selection


Conventional endodontic retreatments are dierent from routine
endodontic therapy in that the tooth already has been treated without
success, a permanent restoration usually has been placed, and iatrogenic
procedural errors must be dealt with. Furthermore, the prognosis for
retreatment is much poorer than that for routine conventional endodontics.
Conversely, through technologic advancements, improved training, and
exceptional restorative techniques, clinicians can obtain successful superior
results. Moreover, conventional retreatment can have a positive eect on the
prognosis, even if surgery ultimately becomes necessary.
Certain teeth that have demonstrated clinical inadequacies in previous
endodontic treatment, however, can be considered a success. A tooth that
exhibits an incomplete obturation to the terminus of the root, yet is

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R. Wong / Dent Clin N Am 48 (2004) 265289

Fig. 1. Considerations for retreatment of an endodontically treated tooth. (From Friedman S,


Stabholz A. Endodontic retreatmentcase selection and technique. Part 1: criteria for case
selection. J Endod 1986;12:28; with permission.)

clinically sound, 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
denitive restoration or recurrent caries are present.
Factors that aect root canal failures can be attained from previous
radiographs. Films that were taken preoperatively and postoperatively
can demonstrate presence, absence, or healing of periapical pathosis. The
history of the previous endodontic treatment can allow the clinician to
discern what treatment was rendered and why. In addition, potential
problems with further treatments can be anticipated if the endodontic

R. Wong / Dent Clin N Am 48 (2004) 265289

269

treatment was performed on a tooth that presented with an abscess, or if


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

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R. Wong / Dent Clin N Am 48 (2004) 265289

271

training and experience of the clinician. The apical extent of the obturation
is always well dened. Overextension of gutta-percha occurs when there is
no apical seal of the root canal system [16]. When this occurs, the obturated
gutta-percha sometimes can be retrieved through the root canal system and
removed from the periapical tissues. Occasionally, however, removal of the
extended gutta-percha results in the disarticulation of the extruded guttapercha mass and may require surgical intervention. Iatrogenic procedural
errors such as transportations, ledges, separated instruments, and perforations contribute to the inability to retreat the system successfully.
Therefore, canals with severe curvatures, dilacerations, calcications, ledges,
and iatrogenic procedural errors may result in endodontic microsurgery.
Finally, when making the decision to retreat or perform microsurgery,
the cooperativeness of the patient must be considered. The clinician also
must be aware of the patients desires, expectations, inuences of time, and
nancial obligations. Furthermore, all alternative treatment plans and the
overall prognosis must be discussed before treatment. After all the data has
been considered and discussed, the patient then can make an informed
decision about retreatment, microsurgery, or possible extraction. The ability
of the operator also must be evaluated. This is extremely important because
several retreatment techniques require training and experience and should
not be attempted otherwise. Therefore, the clinicianwhether general
practitioner or specialistmust evaluate each case and assess the operators
capability for treatment or referral accordingly.

Gaining access to the root canal system


Establishing access to the treated root canal usually is dicult. Many
retreatment cases are restored with a post, core, and crown. The removal of
coronal restorations sometimes is unnecessary and contraindicated. Satisfactory and esthetic restorations are expensive and should be considered as
a service to the patient. As a result of trying to keep costs to the patient at
a minimum, clinicians typically access through the restoration if it is intact and
deemed to be functional. Retained coronal restorations also facilitate rubber
dam placement, prevent leakage, and allow for easier temporization.
However, all restorations of poor quality, poor marginal adaptation, and
those that present with recurrent caries should be removed completely to
facilitate the retreatment process [29]. Endodontically, the decision to remove
the coronal restoration is due primarily to the requirement of additional access
to facilitate the retreatment process. Removal of the coronal restoration in
conjunction with the surgical operation microscope allows for enhanced
b

Fig. 2. (A) Preoperative radiograph of abscess in tooth before treatment. (B,C) Initial
examination with probing depths. (D) Examination with microscope and capillary tip to locate
vertical fracture.

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R. Wong / Dent Clin N Am 48 (2004) 265289

assessment of tooth morphology. Furthermore, radiographic information


such as the identication of perforations, untreated root canal systems, and
the coronal extent of silver cones can be detected. Vertical fractures also may
be identied easier once the restoration is removed, and enhanced access for
the clinician also can be obtained.

Facilitated post removal


Access for endodontic retreatment cases usually includes removal of
a post and core. The literature provides evidence that a post space can cause
a vertical root fracture, due to weakening of the integrity of the canal wall
[4042]. Therefore, removal of a prefabricated or cast post can cause root
fractures. The risk increases with long, well-tted, larger-diameter posts [29].
Therefore, before retrieval of the post, all core materials that are in contact
with the post and with the pulp chamber must be removed. Cast post and
cores should be reduced to a single post preparation before removal. Once
straight-line access to the pulp chamber is created, the remaining core
material is removed from the post. Thin diamond burs and piezoelectric
ultrasonics can assist with the nal removal of the core around the post.
Special instruments have been designed to facilitate the removal of posts
[5,16,20,43,44]. However, studies agree that the retention of the post should
be reduced rst with the use of piezoelectric ultrasonics before its removal
[5,41,4348]. Ultrasonic vibrations can be used to disintegrate the cement
and trough around the post to help with the loosening and removal. The use
of ultrasonics alone can be sucient to remove several posts.
Another instrument that allows for increased vibrations is the rotosonic,
Roto-Pro bur (Ellman International, Hewlett, New York) The Roto-Pro
bur is a six-sided, noncutting instrument that comes in two shapes: the
regular straight tip bur and the football-rounded bur. The bur is placed in
a high-speed handpiece and rotates along the side of the post. It is kept in
intimate contact in a counterclockwise fashion to facilitate loosening and

Fig. 3. Use of ultrasonic device to reduce cement and retention of cast post.

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273

Fig. 4. (A) Preoperative radiograph with clinical crown and post broken at the gingival margin.
(B) Placement of tubular taps. (C) Placement of extraction pliers. (D) Postoperative radiograph.
(Courtesy of Dr. William Goon.)

removal of any post (Fig. 3) [5]. However, caution must be observed when
using either of these instruments. In a preliminary study at the University of
the Pacic School of Dentistry [49], the use of piezoelectric ultrasonics
without the use of a coolant such as water resulted in a bony dehiscence.
Therefore, it is recommended that the use of ultrasonics or rotosonics be
used in conjunction with a constant, irrigating, and coolant such as water.
Occasionally the post can break and cause obstructions in the canal,
which results in unforeseen complications [20,44]. Also, sonic vibration may
not be enough to retrieve posts from the root canal system. Therefore,
devices have been made to add forces along the long axis of the tooth to
enhance post removal [5,20,43,44]. These devices are the Gonon Post Puller,
the Ruddle Post Removal System, and the Masserann Kit. The Gonon Post
Puller and Ruddle Post Removal System (SybronEndo, Orange, California)
are equipped with trephine burs that allow for the milling of the coronal
1 mm to 3 mm of the post itself, and have corresponding-sized tubular taps.
Rubber cushions are placed on the taps before mechanical threading of the

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R. Wong / Dent Clin N Am 48 (2004) 265289

Fig. 4 (continued )

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

R. Wong / Dent Clin N Am 48 (2004) 265289

275

Fig. 4 (continued )

a mechanical device to grasp the post. Ultrasonic vibration also can aid in
the retrieval of the post, as mentioned above [5,6]. The disadvantage of the
Masserann Kit is the initial unwarranted removal of excess dentin from
around the post.

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
lling materials in the canals. Obturated canals are lled mostly with either
semisolid materials such as gutta-percha, pastes, and cements or with solid
materials such as silver points and Thermal obturators. Sometimes
a clinician can encounter disarticulated instruments as well.
Semisolid material removal
Removal of gutta-percha can be obtained with several techniques.
Considerations for the removal of gutta percha depend on the initial

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R. Wong / Dent Clin N Am 48 (2004) 265289

Fig. 4 (continued )

examination and the quality and extent of the lling material. Table 2
summarizes considerations with regard to the elimination of gutta-percha in
the canal. The quality of the obturation must be identied. The fastest way to
retreat a canal is to pull out the gutta-percha [29]. This is especially true when
the canal is not condensed well [16]. Using any type of forceps or a Hedstrom
le can remove the lling material immediately. However, when the canal is
well condensed, it may necessitate the use of other instruments and techniques
to facilitate removal. Before the use of these techniques, the extent of the lling
material and the canal curvatures must be noted. Removal of the coronal
portion of the gutta-percha can be achieved with heat caries such as the TouchN-Heat (Kerr Corp., Glendora, California) or System B (Analytic Endodontics, Orange, California). Gates Glidden burs (Dentsply Maillefer, Ballaigues,
Switzerland) also are quite eective in the removal of the coronal portion of
the lling material. Recent studies [5054] have demonstrated the successful
use of nickel-titanium rotary les as well. Once the coronal portion of the
lling material has been removed, other techniques and devices then can be
employed readily.

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277

Fig. 5. (A) Preoperative radiograph of separated post in lower incisor. (B) Depth of
trephination and use of Masserann Kit. (C) Postoperative radiograph of post removed.
(Courtesy of Dr. William Goon.)

Solvents have been used in the past to soften and dissolve gutta-percha
[16,5558]. However, all solvents are somewhat toxic to patients and should
be used with caution [55,57]. Solvents available for dissolution of guttapercha lling material are as follows: (1) chloroform, (2) eucalyptol, (3)
xylene, (4) methylechloroform, (5) halothane, (6) turpentine oil, (7) pine
needle oil, and (8) white pine oil. Chloroform is the most commonly used
solvent, due its eectiveness of dissolution [55,57,58]. It also is relatively
inexpensive and easy to use. When small, underprepared and curved canals
need negotiation, chloroform and small K-type les are best suited. The
sequential technique involves relling of the created reservoir in the canal
orice with drops of chloroform and picking into the dissolving guttapercha while ling with a size 10, 15, and 20 stainless steel le. This is
continued until the terminus is negotiated, after which all solvents should be
discontinued. Sequentially larger K-type les then are inserted into the canal
until all the gutta-percha mass is removed.

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R. Wong / Dent Clin N Am 48 (2004) 265289

Fig. 5 (continued )

Researchers have reported that the newer nickel-titanium rotary instruments can facilitate the removal of gutta-percha in the canal [5054].
Caution should be taken when using rotary les around curvatures and
underprepared canals, however, because disarticulation can occur, resulting
in complications of the retreatment. Nevertheless, the use of stainless steel
hand les, with and without the use of solvents, has proved to be more
eective in complete removal of the lling material from the canal wall
[50,5254,59]. Moreover, the use of the surgical operation microscope has
been documented to improve the entire removal of gutta-percha from the
canal walls (Fig. 6) [59]. Chloroform unfortunately is classied as a beta-2
carcinogen [55,57]. Eucalyptol, an alternative, is less irritating than is
Table 2
Considerations for gutta-percha removal

Condensation
Shape of canal
Length

Pull out

Dissolve

Poor
Straight
Overextended

Well
Curved
Incomplete

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Fig. 5 (continued )

chloroform and has an antibacterial eect [55,57]. It is, however, a lesseective gutta-percha solvent and must be heated to improve the solubility
of the gutta-percha mass.
The geographic location at which the endodontic therapy was performed
can aid in the decision of the retreatment. Pastes and cements can be
grouped into categories of soft and hard setting as well as impenetrable and
irremovable [5]. Pastes that often are found in root canals performed in
Russia, Eastern Europe, and the Pacic Rim pose complications due to the
hardness of the material [5], whereas pastes and cements that are used in the
United States are usually soft and can be removed readily [5]. The extent of
the lling material is again of the utmost importance. Usually the coronal
portion of the canal is obturated with the paste or cement, leaving the
middle and apical portion of the canal free of obstruction. However, one
must commonly deal with ledges, transportations, and calcications.
Disintegration of the coronal portion of the paste or cement can be
enhanced with piezoelectric ultrasonic vibrations [5,6,60,61]. Use of
a microscope also will facilitate removal of the lling material in the
straight portion of the canal. The use of ultrasonic vibrations will allow for

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Fig. 6. (A) Preoperative radiograph of incomplete failing root canal. (B) Postoperative
radiograph of root canal fully treated after removal of the silver point gutta-percha, and
localization of the second mesial canal with the aid of the microscope.

the hardest of materials to be removed [5,6,61]. Caution must be exercised


with the amount of heat generated from the sonics, and irrigating coolant
must be engaged. Heat has some eect on soft porous materials, but is
limited in its usefulness. Gates Glidden burs also are useful with soft
material, but do not aord great credibility with hard pastes and cements.
The use of end-cutting nickel-titanium rotary instruments such as the
Quantec le (SybronEndo, Orange, California) can be advantageous (Fig.
7). The end-cutting les, although dangerous, can be helpful in penetrating
the lling material and facilitate its removal. Solvents such as Endosolv R
and E (Endoco, Memphis, Tennessee) also can be helpful to soften the
formidable material [5]. The R is used for resin-based materials, whereas
the E is used for eugenol-based materials.
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. 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

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281

Fig. 7. (A) Preoperative radiograph of an abscessed molar with a paste ll. (B) Postoperative
radiograph revealing second mesial buccal canal. The Quantec le and ultrasonics were used to
remove the paste ll.

over time. The extent of the obturation is signicant. Overextended points


have a higher anity for disarticulation into the periapical tissues and may
require surgery. The quality and the diameter of the silver point must be
considered when retrieval techniques are employed. Thin points have
a tendency to dislodge with ease and can break more easily, whereas larger
diameter silver points have an anity for the canal wall and can be more
dicult to bypass and remove. Luckily, most canal preparations have
a coronal portion of the canal that is ared whereas the silver cone is parallel
in shape. The area of the ared preparation is advantageous for the removal
of the silver point by the clinician [5]. However, the operator also must note
that silver points are brittle and can fracture easily.
Before beginning any removal technique, a microscope should be used to
ensure that all core build-up material and excess cements around the silver
point are removed. After exposing the silver point, a microneedled forceps,
Steiglitz forceps (Chige, Long Island, New York), or a hemostat can be used
to grasp the object. The operator should test the resistance of the silver point
in the canal with a controlled tug on the forceps. Rather then pull along the
long axis of the canal, the clinician should manipulate the forceps with

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Fig. 8. (A) Preoperative radiograph of a root canal failure with silver points. (B) Radiograph of
one silver point separated in the apical third. (C) Use of the twisted Hedstrom technique. (D)
Radiograph of silver point retrieval. (E) Postoperative radiograph.

a fulcrum to elevate the silver point out of the canal. Too often, the operator
will pull straight upward to mimic a post removal and the silver cone
disarticulates into the canal, resulting in unforeseen complications [5,16,27].
If the silver point has tension and resistance, then the use of ultrasonics on
the forceps for an indirect vibration can help to loosen the point and remove
the obstruction. Placement of ultrasonics directly on a silver cone will
disintegrate the material, and should be avoided [5,16,27,45].
When the obstructed silver point fractures, the object must be located
with an exposed radiograph and bypassed with K-type les. Use of smalldiameter 08 and 10 les along with a chelating agent will assist in the task. A
radiograph should be exposed once the terminus has been negotiated. Upon
negotiation of the apical foramen, sequential enlargement of the canal wall
is obtained. The operator must increase the size of the canal until it is
possible to bypass the impediment with Hedstrom les on two to three sides.
Twisting the handles, as well as the positive rake angles of the instrument,
will make it easier to grasp the obstruction from the canal [5]. A hemostat
can be used to grasp the le handle. A cotton roll is then positioned for

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283

Fig. 8 (continued )

leverage and the hemostat is rotated over it to remove the silver point.
Another radiograph is exposed to ensure that the obstructed lling material
was removed (Fig. 8).
When an object cannot be bypassed or the silver point demonstrates
a larger diameter, then extracting devices such as the post removal systems
or the Endo Extractor Kit (Kerr Corp., Glendale, California) can be used

Fig. 8 (continued )

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285

Fig. 9. (A) Preoperative radiograph of failing endodontic treatment with Thermal. (B)
Successful retreatment of the case using indirect ultrasonic vibration to remove the metal cores.

[43]. The Endo Extractor Kit has four trephine burs that correlate to les
with dierent diameter sizes. The use of cyanoacrylate adhesives aids in the
adhesion of the silver point to the extractor. Silver points are soft and can
erode with mechanical manipulation from trephine burs. Therefore,
choosing the exact trephine is extremely important. The trephine bur
removes approximately 3 mm of surrounding dentin. An extractor with
adhesive in the cannula is selected and placed over the object. After the
adhesives are set, the extractor is checked for resistance; ultrasonic vibration
can ensure the removal of the obstruction, as discussed earlier.
Thermal obturators (Dentsply, Tulsa Dental, Tulsa, Oklahoma) are
either metal or plastic carriers of gutta-percha. Carrier-based obturators
originally were designed with metal carriers [62]. The manufacturer has since
changed the carrier to plastic, which, unfortunately, is more dicult to
remove. Occasionally, in a few number of cases, a metal obturator will
present itself as the original obturation material. The metal obturator has
cutting utes that entangle the surrounding gutta-percha and make it more
dicult to retrieve and remove the obstacle [62]. The rake angles also will
present a problem with retrieval as they can engage the dentinal wall [5]. The
coronal portion of the canal and obturator should be accessed using the
post-removal techniques described above. The metal obturator can be

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grasped with a forceps similar to the silver cone removal technique


mentioned above. By emplying the fulcrum and leverage technique, the le
can be removed readily [63]. Direct or indirect use of ultrasonics can loosen
the metal carrier from the canal wall and gutta-percha, to facilitate removal
as well (Fig. 9). In addition, applying heat to the metal framework can
dissolve the gutta-percha. The plastic obturator can be removed forcefully
without removal of the gutta-percha mass surrounding it. Plastic obturators,
like silver points, will erode with the use of ultrasonic vibration.
Furthermore, the use of heat will melt the plastic, creating further diculties
in retrieval of the obstacle. Solvents can be used to remove coronal guttapercha and bypassing with hand les can loosen the obstruction for both the
metal and plastic carriers [5,64]. Once the carrier is loosened, removal with
twisted Hedstrom les can be accomplished. Another technique uses heated
Hedstrom les and insertion directly into the plastic carrier. The clinician
places two to three Hedstrom les into the core of the carrier and waits for
them to cool. The heated les penetrate the plastic and, after they cool, the
plasticwhich becomes welded to the lescan be removed with ease using
the fulcrum technique and forceps. Nickel-titanium rotary instruments can
also be used in the removal of plastic carrier-based systems. Upon removal
of the carrier and gutta-percha, routine conventional retreatment can ensue.
Summary
Technologic advancements in dentistry and specically 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.
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or a solvent. J Endod 1999;25(11):761.

Dent Clin N Am 48 (2004) 291307

Perforation repair and one-step


apexication procedures
Samuel I. Kratchman, DMD
Department of Endodontics, School of Dental Medicine, University of Pennsylvania,
240 South 40th Street, Philadelphia, PA 19104-6030, USA

As with any dental treatment, procedural mishaps can occur during root
canal therapy. One such occurrence is the perforation of a root or pulpal
oor. When this occurs, the most important step is to seal this perforation as
quickly as possible, avoiding potential contamination from surrounding
tissues. If the perforation occurs in a general dentists oce, the dentist should
contact the local endodontist and request perforation repair on that same day.
After a perforation occurs, the goals are to sterilize (decontaminate) the site
and then seal the perforation. The material most widely used in endodontics
to seal perforations is mineral trioxide aggregate (MTA; Dentsply
Dental,York, Pennsylvania). MTA is extremely biocompatible, and it has
been shown histologically that osteoidlike material grows right into MTA [1].
Before placing MTA over a perforation site, the area should be copiously
irrigated with sodium hypochlorite. This irrigant is the one most commonly
used in endodontics and will help to clean the site.
Full-strength sodium hypochlorite is 5%, but most practitioners use
a diluted form that is mixed with approximately 50% water. The diluted
solution of sodium hypochlorite is as eective as the full-strength solution
for cleansing, with less potential toxicity.
After the perforation site has been soaked with sodium hypochlorite
for approximately 5 minutes, hemostasis and a barrier must now be
achieved. Even though MTA sets in the presence of moisture, as dry a site as
possible should rst be established because MTA (when mixed into
a sandy slurry) is dicult to manipulate and to place. A physical barrier
must be achieved at the perforation site to prevent MTA from being packed
into the bone or through the pulpal oor into the furcation site.
To achieve hemostasis and a physical barrier, there are several materials
available, including various collagen-type materials such as collatape
E-mail address: sikratch@aol.com
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.003

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Fig. 1. Perforation made with an overly aggressive post system.

Fig. 2. Perforation sealed same day with calcium sulfate and MTA.

Fig. 3. Three-year follow-up.

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293

Fig. 4. Old furcation perforation that was not sealed.

(Centerpulse Dental, Carlsbad, California) and calcium sulfate (Class


Implant, Rome, Italy). These materials are resorbable and are needed to
help create a dry eld and a solid area against which the operator packs
MTA. This procedure is best performed under a surgical operating
microscope that provides great magnication and illumination [2]. The
microscope allows for precision in sealing these perforation sites. If choosing
calcium sulfate as a barrier, only a small amount of material is required and
the working time is fairly short. The calcium sulfate powder is mixed with
a liquid that is packaged together, and while in a pastelike form, it can be
placed through the perforation site using an S-Kondenser (Obtura/Spartan,

Fig. 5. Four-year follow-up after perforation repair.

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Fig. 6. Lateral lesion associated with perforation of mandibular bicuspid.

Fenton, Missouri). The S-Kondensers come in three sizes and are doubleended, with one side made of stainless steel and the other end made of
nickeltitanium. The proper sized S-Kondenser is chosen before the calcium
sulfate is mixed, depending on the size of the perforation. After placement,
the calcium sulfate will set over the next minute or so to a stonelike
consistency. The barrier is now in place and MTA is ready to be placed.

Fig. 7. Repair with collatape and MTA.

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295

Fig. 8. One-year follow-up.

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

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Fig. 9. Maxillary incisor with open apex.

perhaps leave a le or paper point in the canal while using MTA so as not to
block the canal.

Clinical cases
Case 1
Perforation made with an overly aggressive post bur [3] (Figs. 13). This
perforation was sealed almost immediately, using a barrier of calcium
sulfate and MTA. The 3-year follow-up shows no signs of bone loss in the
furcation and no clinical depth greater than 2 mm.

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297

Fig. 10. Calcium sulfate placed as an apical barrier and obturated with gutta percha.

Case 2
Perforation occurred during retreatment by one endodontist and was
referred to a second endodontist after several weeks (Figs. 4 and 5). This
perforation was through the pulpal oor, and this situation along with
the amount of time between the perforation occurring and being sealed
(allowing for contamination) decreased the prognosis for this case [4]. The
aforementioned technique was performed, using calcium sulfate as a barrier
and MTA to seal the perforation. The follow-up radiograph shows that this
case was successful, with furcal bone intact and no periodontal probing
depth greater than 2 mm.

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Fig. 11. One-year follow-up.

Case 3
Retreatment case of a mandibular bicuspid with an existing perforation
from the rst endodontic treatment that most likely occurred while the
practitioner was looking for an additional canal (Figs. 68).
The preoperative radiograph for the retreatment shows bone loss on the
lateral side of the root due to the perforation and shows a periapical lesion
due to the fact that an untreated canal existed [5]. What makes this case even
more challenging is that while sealing the perforation on the lateral side of
the root in the midroot region, the clinician must be careful not to block the

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299

Fig. 12. Maxillary incisor with blunderbuss apex and thin walls.

canal with the barrier material, especially because there is also a second
canal that needs to be negotiated for the rst time. For this reason, collatape
was chosen as the barrier material, which can more easily be manipulated
and packed through the perforation while maintaining the patency of the
canals. Collatape comes in strips of collagen-type material that the
clinician folds into a small piece and, with the S-Kondensers, packs it
through the perforation site into the surrounding bony space. This collagen
membrane resorbs, so it is acceptable to be extruding into the surrounding
bone/tissues of a tooth. The missed canal was located after the gutta percha
was removed from the other canal and both canals were treated. While in
the process of warm vertical obturation, the gutta percha was removed

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Fig. 13. Physical barrier of calcium sulfate beyond apex and MTA in apical third of canal.

apical to the perforation site, making room to pack the collatape out
through the perforation, and then a layer of MTA was placed to seal o the
site and the other canals were obturated with warm gutta percha. A 1-year
radiographic follow-up shows healing of both the periapical and the lateral
lesions, with no periodontal probing depth greater than 2 mm.

One-step apexication
Another use for the barrier/MTA technique is for one-step apexication
cases. In the past, cases with open apices were often treated over several

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301

Fig. 14. Gutta percha obturating remainder of canal.

appointments, using intracanal medicaments, with the hope of creating


a calcic barrier against which gutta percha could eventually be placed.
The treatment could be as long as a year, with still no establishment of any
apical barrier formation. These roots were often thinner and, therefore,
more brittle; extending treatment over a long period of time without
providing a permanent restoration increased the chances of losing these
teeth due to fracture. Similar to the technique described previously for
sealing perforations, 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. Calcium sulfate and MTA are

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Fig. 15. Two-year follow-up.

placed using either an amalgam carrier or the at end of a Glick condenser


and packed down the canal with S-Kondensers and using the last size le (ie,
size 100 to 140 K le) so as to better gauge the depth of the calcium sulfate/
MTA placement by moving the rubber stopper down the le coronally as
more material is placed in the canal. After MTA is rmly packed, the rest of
the canal can be easily lled using the Obtura II (Obtura/Spartan, Fenton,
Missouri), with vertical compaction of warm gutta percha. Before the
advent of warm vertical condensation, lling cases such as these would be
time-consuming, require an entire pack of accessory gutta percha points,
and still often end up with voids.

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Fig. 16. Maxillary incisor with open apex.

Clinical cases
Case 4
Figs. 911 show a maxillary central incisor with an open apex in which
calcium sulfate was placed and a rm apical stop manufactured. Instead of
MTA in this case, a master cone of gutta percha was placed with tug back,
conrmed radiographically, and then completed by removing all but the
apical 5 mm of gutta percha using the System B heat transfer unit (Sybron
Endo, Orange, California) and backlling with the Obtura II. A 1-year
radiographic follow-up shows intact periapical bone and no sign of
pathology.

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Fig. 17. Canal lled with calcium hydroxide to attempt apexication.

Case 5
Figs. 1215 show a maxillary central incisor with a blunderbuss apex and
thinner walls than the previous case. A small periapical lesion is present. To
create a barrier, calcium sulfate was placed apically, extruding into the
periapical area but forming a physical barrier against which MTA can be
packed at the root end. MTA lls the apical 3 mm of the canal, and the
rest of the canal is obturated with warm gutta percha [6]. An often-asked
question is, Why not ll the entire canal with MTA? There is really no
benet to doing this because MTA is much more expensive and more timeconsuming to place than gutta percha. Radiographic follow-ups at 2 years
show complete healing periapically and no pathologic signs.

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305

Fig. 18. After several placements of calcium hydroxide, still no calcic barrier apically.

Case 6
Maxillary central incisor with an open apex in which apexication
was originally attempted by multiple calcium hydroxide placements [7]
(Figs. 1619). After this failed attempt to create a calcic barrier, the
one-step apexication technique was performed, using calcium sulfate and
MTA. A radiograph conrms the calcium sulfate in place (sealing o the
apical tip of the root), MTA in the apical few millimeters of the canal, and
the nal gutta percha placement. A slight demarcation can be seen between
MTA and gutta percha, but the radiopacity is almost identical.

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Fig. 19. One-step apexication with calcium sulfate, MTA, and gutta percha.

This technique of one-step apexication oers an alternative to those


drawn-out cases with several medicament-changing appointments that often
resulted 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 [8]. Completion of these cases in an eective and ecient way
allows for permanent restorations to be done in a more timely manner,
prolonging the longevity of these teeth.
References
[1] Koh ET, McDonald F, Pitt Ford TR, Torabinejad M. Cellular response to mineral trioxide
aggregate. J Endodon 1998;24:5437.

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[2] Carr OB. Magnication and illumination in endodontics. In: Clarks clinical dentistry, vol. 4.
St. Louis (MO): Mosby; 1998. p. 114.
[3] Akkayan B, Gulmez T. Resistance to fracture of endodontically treated teeth restored with
dierent post systems. J Prosthet Dent 2002;87:4317.
[4] Pitt Ford TR, Torabinejad M, McKendry DJ, Hong CU, Karyiyawasam SP. Use of mineral
trioxide aggregate for repair of ircal perforations. Oral Surg 1995;79:75662.
[5] Lee SJ, Monset M, Torabinejad M. Sealing ability of mineral trioxide aggregate for repair
of lateral root perforations. J Endodon 1993;19:5414.
[6] Shabahang S, Torabinejad M. Treatment of teeth with open apices using mineral trioxide
aggregate. Pract Periodontics Aesthet Dent 2000;12:31520.
[7] Sheehy EC, Roberts OJ. Use of calcium hydroxide for apical barrier formation and healing
in non-vital immature permanent teeth: a review. Br Dent 1997;183(3):2416.
[8] Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate.
J Endodontics 1999;25:197205.

Dent Clin N Am 48 (2004) 309321

Modern oce design in the


information age
Garrett Guess, DDSa,b,*
a

Private Practice, 8929 University Center Lane, Suite 209, San Diego, CA 92122, USA
b
Department of Endodontics, University of Pennsylvania School of Dental Medicine,
240 South 40th Street, Philadelphia, PA 19104-6030, USA

The modern dental oce in the information age of today bears little
resemblance to the oces built 20 or even 10 years ago. The focus of
providing superior and eective patient care remains the same, but the
method of delivery and presentation has changed thanks to improvements in
technology on many fronts. Most inuential in this change has been the
widespread use of computers and computerized peripherals in providing
dental treatment and educating patients about the treatment they are to
receive. The information age, which represents the use of computers to share
and maintain information, has had many inuences in the eld of dentistry,
especially in endodontics. These inuences have begun to change the daily
practice of dentistry by aecting the standard of care and, most apparent,
the overall design of the modern dental oce to allow the use of and to take
advantage of these technologic changes. Like putting the pieces of a complex
puzzle together, this article reviews the process of reaching the goal of
modernizing a new or existing endodontic oce.
Most of the advancements in the modern endodontic oce revolve around
the use of computers that act as hub between the various components. It is
not rare to nd a modern endodontic practice using computers to capture
digital video and still images of treatment, to take and store digital
radiographic images, and to chart the patients treatment information.
Computers in the dental practice are not a new occurrence. For many years,
computers have been used to schedule patients, store patient information, do
billing, and in more advanced cases, perform comprehensive charting. By
using a computer system to manage the information used by the practice,
greater eciency is achieved on many levels. The most important advances in

* Private Practice, 8929 University Center Lane, Suite 209, San Diego, CA 92122.
E-mail address: guessendo@mac.com
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.10.004

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

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Fig. 1. Practice management software is the hub connecting and managing all other
technologies utilized in the endodontic practice.

or incapable. Therefore, the choice of stable hardware on which to run the


software is important, as is the setup of the system to ensure that it is
trouble-free. The various practice management software packages available
perform the same overall function, but dierent programs do it in very
dierent fashions. Some systems are designed by practicing dentists, whereas
others are made by consultants and computer programmers; certain
programs are designed for specialty practices, whereas others are made
for a dental oce in general; and some systems have severe limitations when
it comes to expansion or upgradingall of these factors are important to
consider. As an endodontist, a program designed specically for the
endodontist often will be a wiser choice over one for dentists in general. The
ow of treatment planning, referral management, and other issues will be
better suited to the daily routines and management of a specialty practice.
There are dozens of computing solutions to manage the dental practice, and
all may work well for an endodontic oce. There are currently four
endodontics-only software packages: three are available for Windowsbased computer systems and one for Macintosh-based computer systems.
The Windows solutions are PBS Endo (PBS, Texas), EndoVision (Discus
Dental, Inc., Culver City, California), and TDO (DogBreath Software, San
Diego, California). The Macintosh system is called EndoTrak (Digital
Database Systems, San Diego, California) and was developed by the author.
These systems all focus on the specic needs of the endodontist in their own
ways and have specic pluses and minuses that need to be evaluated by the
prospective dentist when choosing between them. Each of these systems
provides comprehensive charting, referral, and practice management, which
are important in an endodontic practice.
Because the nancial and time investment is large when purchasing
programs and training personnel to use them, the longevity of the system is
important. Considerations with regard to expansion and compatibility are
also crucial. The abilities of a software program to eciently incorporate
dierent peripherals such as video input from a microscope or a digital still

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

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pictures with the operating microscope, and this capability should be


considered as part of the requirements of the imaging system. The majority
of microscope manufacturers have the ability to output a video signal from
an optional camera mounted within the microscope. 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. Recording and
presenting this media to patients and referrals is an impressive method of
education and relaying information about treatment plans and outcomes. It
allows a patient or referral to see exactly what is being treated. To perform
this function, the proper wiring that links the microscope and the computer
needs to be present. This connectivity allows a computer program to import
and store video and still images that are seen through the operating
microscope camera. These images can be added to a patients chart or put in
a report to share with referrals. Documentation using images is invaluable
with respect to certain liability and consent issues.
When viewing video images and patient charting in the operatories, it is
benecial to have several displays that show the output from the computer.
Especially with digital radiography systems, having a display behind the
patient allows for the viewing of radiographic images in the manner similar
to viewing conventional lm with respect to the tooth location (Fig. 2).
Also, a monitor for the assistant to view during treatment is helpful to allow
data entry into the chart as treatment is occurring. For example, one computer
screen with which the assistant can interact can show the chart for data entry
during treatment and is placed at the 12 oclock position in the operatory,
whereas another screen can display the working radiographs for the doctor to
reference on the doctors side of the operatory (Fig. 3). The exact placement of
the multiple monitors is determined by each dentists preference. Flat-paneled
monitors take up little wall space and are simple to wall-mount, so it is
possible to place these screens in dierent locations with ease. 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. It is clear that as more functions are added, demand for a more
complex infrastructure arises. Planning the current and future wiring needs
should be closely evaluated before construction or remodeling begins to
account for all possible congurations that may be tried now and in the future.
Computer systems have evolved tremendously over the last 5 years. The
evolution has been spurred by the changes and new technologies incorporated
in the computer systems themselves. With tighter integration of many
software components, computers have been able to tackle just about every
task presented in a tight-knit fashion. Where Hi-8 8-mm video tape decks
were used to record surgical procedures, a computer can now record the video
with digital quality that can be edited into educational and informative media
with many uses. Still imaging is handled by computers in the same way.

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Fig. 2. Computer monitor placement on the wall behind the patient for exible computer
viewing and input by the sta and/or doctor.

Instead of a photographic lm-based camera system, digital images can be


stored and sorted for each patient with little turnaround. These images can be
transferred to a digital chart of the patient and stored for later viewing or sent
to referrals or benet providers.
As the complexity of the technologies and their related systems increases
in the dental oce, so does the requirement of an increased knowledge base
for those who use the equipment. The doctor and sta must understand and
be fully capable of using the new technologies to their fullest extent to make
the transition worthwhile and less disruptive. 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 eciently. Unfortunately, learning new
technologies can be very dicult, especially for those who are unaccustomed
to computers and their usage. Usually, the largest hurdle to overcome is
learning the software program that manages the oce. Some of these

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Fig. 3. Doctor and sta working shown with an operating microscope and integrated video
camera, displaying the video through a chairside computer station.

programs have such a large number of features that it is a challenge to


master them all. The other equipment such as the setup of the servers and
the network can be left to contracted consultants. Most companies oer
training manuals, videos, and training sessions to familiarize the oce with
their programs. When hiring personnel in the modern dental oce, it is
important to research the training and experience of potential employees
because training is a dicult and long process when starting at ground zero.
One of the most substantial changes in a modern dental oce is the
movement of computers from the front oce to the operatory where
patients are treated. With the addition of computer workstations in the
oce, a networking infrastructure is used to share information among the
computers in the oce (Fig. 4). Taken one step further, computer systems in
separate oce locations can be linked for a reasonable cost by means of the
Internet. Dental oces have approached enterprise-level complexity in the
use of computer systems and the networks that link them together. This
complexity can be achieved thanks to signicant advances in the hardware
and software that allow these capabilities. Such complexity would have
required a full-time sta of trained network experts just 10 or 15 years ago,
but not today. A networked dental oce can share all parts of patient
information between the front oce and operatories and remotely between
separate oces in dierent locations. No longer is information in an
irretrievable, inecient storage statethe written patient chart. Computer
software systems that manage the dental practice allow the archiving and
storing of countless numbers of patients. All information stored within these
records can be sorted and sifted through instantaneously. The eciency of
this arrangement over an older written patient chart is incredible. With

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Fig. 4. Network connections between computers in the same oce, and between oces to
permit the sharing of patient and practice data.

increased power and capability of computer hardware, networking, and


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

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A new type of practice management software system is designed to take


advantage of the networking capabilities of the Internet. Instead of the usual
in-oce computer server, the server with all of the oces information is
located o-site and managed by an outside company. Therefore, to access
treatment information for the patients in the oce, the server is accessed
over the Internet using a Web browser instead of proprietary software like
most practice management software programs. 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. Through this
kind of setup, patient charts and information can be accessed anywhere that
access to the Internet is available. This method is less popular but likely to
be the wave of the future as Internet reliability and security increases.
Clinical research capabilities have been strengthened by the use of
computerized charting systems in dentistry. 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 dierent variables. This type of information
allows a private practice clinician to have an evidence-based practice using
data from his or her own practicing techniques. This information is
invaluable because some procedures work well in some doctors hands,
whereas others do not, and with an ecient method to track and study this
information, signicant ndings can be obtained. With the lack of published
clinical research data from private practice practitioners, this powerful
feature of increased technology has exciting potential.
A computer system in the treatment operatory allows many aspects of
treatment presentation, documentation, and education to be changed.
Digital radiography has become a diagnostic tool that many dental oces
are taking advantage of for many dierent reasons. 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. 5). It is clearly more ecient
than chemical processing, does not require a signicant time lag in the
development process, and does not require maintenance of the processing
equipment. 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 allows subtle repositioning of the x-ray cone
to get various angled images with greater accuracy and less retakes. For
example, if a midoperative working radiograph is taken and one root is
superimposed on another, then the x-ray cone can be moved slightly in one
lateral direction and the sensor re-exposed. With a standard lm, when an
incorrect angle results, another lm 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 lm assembly is removed and then replaced. By not
having to move the sensor in the patients mouth, more accurate changes in
angulation can be performed. This feature enhances the midoperative
diagnostic accuracy of the practitioner, especially in multirooted teeth

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Fig. 5. Digital xray system: wired sensor connected to a USB interface with the computer. The
exposed sensor produces an image on the computer display for viewing and manipulation.

because each root end can then be visualized over a series of angled digital
radiographic images before progressing. From a waste and materials-usage
standpoint, there are no chemicals to maintain or change, so digital
radiography has no per-use cost other than the storage space on the
computer that the digital image le requires. Also, with most systems using
newer image compression routines, the le sizes are extremely small relative
to the storage available. Digital radiography also has several sta, doctor,
and patient health benets because the radiation dose exposure is
signicantly decreased. Compared with the fastest E-speed lm that may
require a 20-millisecond exposure at 70kVp, the same quality image can be
obtained with a digital radiographic system using just 3 milliseconds of
exposure time with the same 70kVp, which is close to a seven-times decrease
in radiation exposure to the patient. Digital radiography allows the doctor
to more easily view the image and greatly facilitates educating the patient
because it allows a large screen-sized image to be viewed on the monitor.
The resolution of the current digital radiographic systems is very good,
greater than most computer screens can display. The image quality is mostly
determined, therefore, by the type of monitor or at panel that is used
because all systems have similar high-quality sensors and resolution
capability. For this reason, high-quality computer displays are an important
investment when considering the purchase of computer equipment for the
modern dental oce.
The benets of digital radiographic systems are clear, but it is the high
cost of the system that keeps most oces from making the change. In
addition, digital radiography must be used with a computer that controls the
radiographic system, so a computer is required in each operatory. To get

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

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already-expensive operating microscope. Digital still cameras also can be


mounted to the operating microscope to take high-quality still images. The
cost of the adapters and camera is similar to an integrated video camera
system, and is often more bulky and less aesthetic that the integrated unit.
The added weight of the still camera and attachments on the scope head is
another drawback to this type of digital imaging solution, sometimes
making the scope less maneuverable. When images are obtainedproducing
printed media for the digital radiographs, postoperative reports, or
imagesthere are many economical printing solutions that can be used.
There are many high-quality, inexpensive ink-jet printers available that
provide excellent output that can be given to patients or sent to referrals or
insurance providers.
For better or for worse, the technologies driven by computers and their
capabilities are a necessity in the successful and ecient dental practice. Can
a practice thrive without the use of computers and their related peripherals?
It certainly can, as thousands of successful dentists have proved over time.
Times are denitely changing, however. Patients are more aware than ever
before of the technologies that are available to dentists. They are learning
more and are becoming more accustomed to seeing technology in all parts of
their own lives and are expecting dental oces to follow suit. In fact,
competition among dentists and especially specialists has become increasingly greater in many urban and suburban locations, making the
acquisition of technology not only a benet from a patient treatment
standpoint but also an eective and necessary marketing tool. 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.
Through high-impact patient education using the tools available today
and in the future, patients can be impressed and educated by the treatment
they receive. 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. In addition, 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; this is where Web sites play
a large role in marketing the dental practice. A Web site can set the tone of
a practice and ease tensions by giving patients pictures so that they know
what to expect. Many patients like to put a face to their doctor before
coming to the oce, and Web sites enable them to do this. All oces should
take advantage of a Web site because it is a relatively inexpensive marketing
tool that can be used eectively for introducing the practice to anxious
patients.
The dening feature of a modern dental oce is not the equipment alone,
but its use. Greater technology and complexity requires greater education
and, often, changes in the way procedures are being performed. Time is
needed to research, purchase, and then learn new equipment, new software

G. Guess / Dent Clin N Am 48 (2004) 309321

321

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

Dent Clin N Am 48 (2004) 323335

Endodontic working width: current


concepts and techniques
Yi-Tai Jou, DDS, DMD*, Bekir Karabucak, DMD, MS,
Jerey Levin, DMD, Donald Liu, DMD
Robert Schattner Center, Department of Endodontics, School of Dental Medicine,
University of Pennsylvania, 240 South 40th Street Philadelphia, PA 19104-6030, USA

A clinicians primary concern is to thoroughly cleanse the root canal


system during root canal therapy, mechanically and chemically removing
microorganisms and their substrates from the canal. Without proper
chemomechanical instrumentation, the remaining irritants may reduce the
success rate and cause failure of the treatment. In addition, canal surface
irregularities require proper instrumentation for adequate root canal lling.
Many textbooks and much literature focus on canal instrumentation in
terms of ling, reaming, or other instrument motions and usage and always
stress the importance of enlarging the canal size. Without solid scientic
evidence, however, it is still not clear how large is large enough.
Many studies have demonstrated that widely accepted endodontic
cleaning and shaping techniques are inadequate. Haga [1] found that
mechanical preparation of root canal to two sizes larger than the original was
still not adequate. Gutierrez and Garcia [2] showed that often, canals are
improperly cleaned. They attributed this inadequate instrumentation to the
fact that the root canal diameter is larger than the instrument caliber used in
each particular case. This nding suggests that each canal should be
calibrated independently before instrumentation so that proper preparation
can be achieved. Waltons [3] histologic study showed that canals that were
instrumented to three sizes larger still were not thoroughly cleaned. Recent in
vitro investigations [15] concluded that stainless steel and nickeltitanium
(NiTi) rotary instruments were not able to clean the root canals satisfactorily.
In the absence of a study that denes what the original width and
optimally prepared horizontal dimensions of canals are, clinicians are
making treatment decisions without any support of scientic evidence.
* Corresponding author.
E-mail address: ytj@pobox.upenn.edu (Y.-T. Jou).
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.006

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Y.-T. Jou et al / Dent Clin N Am 48 (2004) 323335

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 [1,57,23], but there have
been few clinical attempts to determine the working width (WW). It is dicult
to section all levels of the teeth and make the section plane exactly
perpendicular to the canal curvature. Therefore, most morphometric studies
cannot show the true picture of the horizontal dimensions of the root canal
system. Until recently, most investigations have involved counting the
number of canals and foramina and categorizing how the canals join or split.
Current studies pay more attention to the shape of the canal systems and its
clinical implications than to the actual, preoperative size of the canal [4,8,9].
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 dicult to investigate because the horizontal
dimension varies greatly at each vertical level of the canal as shown in Figs.
13. Routine clinical radiographs may mislead clinicians to make a dierent
plan to clean the root canal system. Unfortunately, this area of critical
information has not been investigated thoroughly. Some clinicians may
still have the impression that all root canals are round in shape because of
such radiographs as shown in Figs. 1 and 2. Recent studies reported a high
prevalence of oval root canals in human teeth [4,8,9]. Cross-sections of 90%
of the mesiobuccal canals of maxillary rst molars were found to be oval or
at [4]. This article provides denitions and perspectives on the current
concepts and techniques to handle WW (the horizontal dimension of the root
canal system) and its clinical implications.

Fig. 1. The mesiodistally directed radiograph indicates a attened distal root canal in
a mandibular rst molar. In the same tooth, the faciolingual direction of the routine radiograph
gives an impression of a round-shaped distal canal.

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325

Fig. 2. The faciolingual direction of the routine radiograph gives an impression of roundshaped canal in a mandibular rst premolar. The mesiodistally directed radiograph indicates
a attened root canal in the same tooth.

Denition 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. In
a relatively round canal, the lesser and the greater initial horizontal

Fig. 3. Cross-section of a mandibular rst premolar, indicating a long-oval and irregular root
canal. In the same tooth, the faciolingual direction of the routine radiograph may be mistakenly
recognized as a round-shaped canal because a mesiodistally directed radiograph is rarely
available clinically.

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Y.-T. Jou et al / Dent Clin N Am 48 (2004) 323335

Box 1. 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. In an oval, long-oval, or at canal as


shown in Box 2, the maximal initial horizontal dimensions (MaxIWW) may
be several times larger than the minimal initial dimension (MinIWW) at
dierent levels of the canal. For example, in a maxillary cuspid, MinIWW at
working length (MinIWW0) may be the same as MaxIWW at working length
(MaxIWW0). But 12 mm short of working length, its MaxIWW12 is
probably three to four times larger than MinIWW12. This is because at that

Y.-T. Jou et al / Dent Clin N Am 48 (2004) 323335

327

Box 2. Current descriptions of the horizontal dimensions


(cross-sections) of the root canal
1. Round (circular): MaxIWW equals MinIWW
2. Oval: MaxIWW is greater than MinIWW (up to
two times more)
3. Long oval: MaxIWW is two or more times
greater than MinIWW (up to four times more)
4. Flattened (flat, ribbon): MaxIWW is four or
more times greater than MinIWW
5. Irregular: cannot be defined by 14

level, the cross-section of a cuspid very often is a long-oval or at canal


shape. After root canal instrumentation, the minimal nal horizontal
dimension at working length (MinFWW0) may be no dierent than the
maximal nal horizontal dimension at the working length (MaxFWW0) if
there was not signicant transportation. At the level of 12 mm short of the
working length, however, the ratio between MinFWW12 and MaxFWW12
may be altered by the mechanical preparation of the canal. In general, there is
a 25% prevalence of long-oval canals in the apical third, and in some groups
of teeth, the prevalence is greater than 50% [9]. 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].

Determination of initial working width at working length (initial apical


le determinationestimation of initial canal diameter)
In the course of cleaning and shaping the root canal system, the clinician
must determine three critical parameters. These are the length of the canal,
the taper of the preparation, and the horizontal dimension of the
preparation at its most apical extent, also referred to as the initial apical
le size. One common method of deciding on the size of the apical
preparation is to rst determine the preoperative canal diameter by passing
consecutively larger instruments to the working length until one binds. This
initial apical le estimation is referred to as the determination of MinIWW0.
In some textbooks, the master apical le size (MaxFWW0) is then suggested
to be three International Standards Organization (ISO) le sizes larger than
that initial binding le (Table 1). Clinicians and researchers started to
question whether the rst le to bind corresponds to the apical diameter of
the canal. Recent studies suggest that the rst K le and the rst LightSpeed
(LightSpeed Technology, San Antonio, Texas) instrument that bound at the
working length did not accurately reect the diameter of the apical canal
[10,11,13,15]. The inaccuracy and discrepancy can come from various

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Y.-T. Jou et al / Dent Clin N Am 48 (2004) 323335

Table 1
Current concepts and guidelines determine the minimal nal working width at working length
from dierent publications
Author and references
Tooth
Maxillary
Centrals
Laterals
Canines
First premolars
Second premolars
Molars
MB/DB
P
Mandibular
Centrals
Laterals
Canines
First premolars
Second premolars
Molars
MB/ML
D

Grossman [17]
8090
7080
6060
3040
5055
305550

4050
4050
5055
3040
5055
305550

Tronstad [20]

Glickman and
Dumsha [19]

7090
6080
5070
3590
3590

3560
2540
3050
2540
2540

3560
80100

2540
2550

3570
3570
5070
3570
3570

2540
2540
3050
3050
3050

3545
4080

2540
2550

Weine [21]
3
3
3
3
3
3
3
3

sizes
sizes
sizes
sizes
sizes
sizes
sizes
sizes

3
3
3
3
3
3
3
3

sizes
sizes
sizes
sizes
sizes
sizes
sizes
sizes

morphologic and procedural factors such as canal shape, canal length,


curvature of the canal, canal content, coronal interference, and the instrument used in estimating or measuring MinIWW0 and MaxIWW0.

Factors aecting the determination of minimal initial working width at


working length
Several factors may aect the accuracy of determining the MinIWW0.
The canal shape, length, taper, curvature, content, and wall irregularities
and the instrument used may all inuence the result because each can aect
the clinicians tactile sense. The combination of those factors makes correct
determination of IWW very dicult, if not impossible. Understanding these
factors can minimize the underestimation of the IWW.
Canal shape
The current descriptions of horizontal dimensions of the root canal
system are listed in Box 2. The round canal can be measured more easily
because the MinIWW and MaxIWW are the same. Other factors, however,
make determination of IWW dicult, even in straight canals. The proper
instrument and tactile sensation may determine the MinIWW of the oval,

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329

long-oval, and at canals. The determination of MaxIWW, however, cannot


easily be realized with current methods.
Canal length
When using an instrument to gauge working length, the longer the canal,
the greater the frictional resistance. In a very long canal ([25 mm), the
frictional resistance may increase to aect the clinicians tactile sense for
determining the IWW correctly. In addition, if the coronal are is too
conservative or limited to the coronal third of the canal, then the shaft of the
instrument may engage the canal wall and cause a false/premature conclusion
as to the WW.
Canal taper
Any tapering discrepancy between the gauging instrument and canal may
lead to an early instrument engagement of the canal wall, causing a false
sensation of apical binding. Early coronal are can increase the taper of the
canal and reduce the tapering discrepancy between the gauging instrument
and canal wall. The last 3 to 5 mm of the canal can have parallel walls,
making correct determination of IWW dicult.
Canal curvature
Curved canals can cause deection of the gauging instrument and
increase the frictional resistance. The curvature of the root canal can be
categorized into two-dimensional, three-dimensional, small radius, large
radius, and double curvature (S-shaped, bayonet-shaped) and with dierent
degrees of severity. Each of these curvatures has a dierent eect on
a clinicians tactile sense. The combination of these curvatures makes correct
determination of IWW extremely dicult, if not impossible. In curved
mandibular premolars, the study by Wu et al [13] indicated that the rst K
le and the rst LightSpeed instrument that bound at the working length
failed to accurately reect the diameter of the apical canal.
Canal content
The content of the root canal may be brous in nature. Calcied material
(calcic metamorphosis) may also be part of the canal content. During
determination of IWW, the mixed canal contents can create dierent degrees
of frictional resistance against the gauging instrument. It can eventually
aect the clinicians tactile sense. This factor makes correct determination of
IWW somewhat more dicult.
Canal wall irregularities
Attached pulp stones, denticles, and reparative dentin can create
convexities on the canal wall surface. Resorption can produce concavities

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Y.-T. Jou et al / Dent Clin N Am 48 (2004) 323335

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

Eliminating or minimizing the inuence of aecting factors


Being aware of the existence of the aecting 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. 47.

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

Y.-T. Jou et al / Dent Clin N Am 48 (2004) 323335

331

Fig. 5. A cross-section of a NiTi rotary instrumentprepared 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 orices, to do


early coronal aring and additional canal aring (crown down, double
aring) to ensure eective irrigation, and to minimize any interferences with
tactile sensation. Carefully selecting the adequate instrument of maximal
exibility 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 lled canals indicates an incomplete instrumentation


and may result in a failed root canal treatment. The dumbbell eects 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.

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Y.-T. Jou et al / Dent Clin N Am 48 (2004) 323335

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

ideal condition, especially for long-oval and attened root canals, they can
be cleaned and shaped properly with minimal mishaps of weakening,
stripping, or perforating the canal walls as shown in Fig. 4D. Circumferential preparation or instrumentation may have to be considered for these
cases to minimize incomplete cleaning of the root canal system. Most of the
NiTi rotary instruments provide a continuous reaming action that makes
the canal relatively circular in shape. Indiscriminate use of NiTi rotary
instruments alone for root canal cleaning and shaping may result in
incomplete cleaning of the root canal system and lead to failure of the
endodontic therapy (Fig. 5). Recent studies [10,12,1416] have indicated
that no current instrumentation technique was able to completely clean
dentin walls of the oval, long-oval, and attened root canals. The manual
crown down instrumentation technique, however, was more ecient and
eective in cleaning attened root canals than rotary instrumentation.

Determination of the minimal and maximal nal working width at


working length
To what extent the canal is supposed to be prepared has been a myth in
the endodontic eld. 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) 323335

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 lling
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 nding. Any investigation of the
eectiveness of cleaning the root canal system without carefully estimating
the MinIWW and MaxIWW in the oval, long-oval, and attened root canals
may result in misleading data, especially if the horizontal canal morphology
was not carefully assessed. In an oval, long-oval or at 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
eectiveness 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
GatesGlidden burs or canal wideners to a round shape instead of following
the original oval, long-oval, or at shape. Although the strength of the tooth
structure is evidently reduced [22], the FWW in the cervical area has been
determined by the clinicians preference instead of scientic evidence. Based
on limited information [1,2,57,1724] 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 scientic 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 at 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 ling had statistically signicant better eectiveness than
rotary instrumentation for cleaning attened root canals [14]. The concepts
of the WW indicate that dierent approaches and techniques are needed to
improve root canal preparation and promote better quality of root canal
treatment.

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Y.-T. Jou et al / Dent Clin N Am 48 (2004) 323335

Summary
There has been minimal development of concepts, techniques, and
technology to measure IWW and to determine FWW accurately or
properly. Understanding the current concepts and techniques of WW can
reduce the underestimation of the MinIWW0 and apical MinIWW and
subsequent incomplete cleaning of the root canal system. The detailed
information regarding horizontal morphology of the root canal system can
help to solidify concepts and improve techniques of cleaning and shaping
the root canal system. Carefully maintaining the aseptic chain, using
adequate irrigating solutions to enhance ecacy, and cautiously applying
current concepts and techniques of WW may provide a better quality of
endodontic therapy for the patient.
References
[1] Haga CS. Microscopic measurements of root canal preparations following instrumentation. J Br Endod Soc 1968;2:41.
[2] Gutierrez JH, Garcia J. Microscopic and macroscopic investigation on results of
mechanical preparation of root canals. Oral Surg 1968;25:10816.
[3] Walton RE. Histological evaluation of dierent methods of enlarging pulp canal space.
J Endodon 1976;2:30411.
[4] Mauger MJ, Schindler WG, Walker WA. An evaluation of canal morphology at dierent
levels of root resection in mandibular incisors. J Endodon 1998;24(10):6079.
[5] Kerekes K, Tronstad L. Morphometric observations on the root canals of human molars.
J Endodon 1977;3(3):1148.
[6] Kerekes K, Tronstad L. Morphometric observations on the root canals of human
premolars. J Endodon 1977;3(2):749.
[7] Kerekes K, Tronstad L. Morphometric observations on the root canals of human anterior
teeth. J Endodon 1977;3(1):249.
[8] Gani O, Visvisian C. Apical canal diameter in the rst upper molar at various ages.
J Endodon 1999;25(10):68991.
[9] Wu MK, Barkis D, Roris A, Wesselink PR. Prevalence and extent of long oval canals in
the apical third. Oral Surg 2000;89(6):73943.
[10] Liu DT, Jou YT. A technique estimating apical constricture with K-les and NT
Lightspeed rotary instruments. J Endodon 1999;25(4):306.
[11] Levin JA, Liu DT, Jou YT. The accuracy of two clinical techniques to determine the size of
the apical foramen. J Endodon 1999;25(4):294.
[12] Weiger R, Lost C. Eciency of hand and rotary instruments in shaping oval root canals.
J Endodon 2002;28(8):5803.
[13] Wu MK, Barkis D, Roris A, Wesselink PR. Does the rst le to bind correspond to the
diameter of the canal in the apical region? Int Endodon J 2002;35(3):2646.
[14] Barbizam JVB, Fariniuk LF, Marchesan MA, Pecora JD, Sousa-Neto MD. Eectiveness
of manual and rotary instrumentation techniques for cleaning attened root canals.
J Endodon 2002;28(5):3656.
[15] Tan BT, Messer HH. The quality of apical canal preparation using hand and rotary
instruments with specic criteria for enlargement based on initial le size. J Endodon 2002;
28(9):65864.
[16] Wu MK, Wesselink PR. A primary observation on the preparation and obturation of oval
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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;17:1928.
[19] Glickman GN, Dumsha TC. Problems in canal cleaning and shaping. In: Gutman L,
Dumsha C, Lovdahl, Hovland E, editors. Problem solving in endodontics. 3rd edition.
St Louis (MO): C.V. Mosby; 1997. p. 114.
[20] Tronstad L. Clinical endodontics. New York: Thieme; 1991.
[21] Weine FS. Endodontic therapy. 5th edition. St. Louis (MO): C.V. Mosby; 1996.
[22] Carter JM, Sorenson SE, Johnson RL, Teitelbaum RL, Levine MS. Punch shear testing of
extracted vital and endodontically treated teeth. J Biomech 1983;16:8418.
[23] Kuttler Y. Microscopic investigation of root apexes. J Am Dent Assoc 1955;50:54452.
[24] Walton RE, Torabinejad M. Principles and practice of endodontics. 3rd edition.
Philadelphia: W.B. Saunders; 2002.

Dent Clin N Am 48 (2004) 337339

Index
Note: Page numbers of article titles are in boldface type.

A
Apex locator(s), electronic, 45, 3554
frequency-dependent, 3738
accuracy of, 3841, 47, 48
operation with various
electrolytics, 4147
problems with using, 5051
suggestions for use of, 49
to detect root perforation, 48
use in primary teeth, 48
with additional functions, 38
history of, 3638
traditional-type, 3637
Apexication procedures, one-step, 300302
calcium sulfate in, 301302
clinical cases illustrating, 303306
mineral trioxide aggregate in,
301302
repair of root perforation and,
291307
Apical foramen, terminus of, gaining access
to, 275286
C
Calcium sulfate, for hemostasis and barrier,
in root canal therapy, 291293, 295
in one-step apexication, 301302
Cavity, access to, extension of, 217
preparation of, obturation of root
canal system and, 217
Collatape, for hemostasis and barrier, in
root canal therapy, 291293
Computers, as hub between oce
components, 309, 311, 315
choosing software program for, 310,
312
decision for, obtaining information
for, 311312
digital radiography systems and, 313,
317318, 319, 321
documentation of treatment using,
312313

endodontics-only software for, 311


for electronic mailing of reports and
radiographic images, 316
for patient education, 309
increasing knowledge base for users of,
314315, 320
practice management software systems
for, 316317
technologies incorporated into, 313
to manage vital information in
practice, 309310
D
Dental oce, modern, computers in. See
Computers.
design of, in information age,
309321
Digital radiography systems, computers
and, 313, 317318, 319, 321
E
Electronic mailing, of reports and
radiographic images, computers for,
316317
Endodontic practice, instruments and
techniques for, 19
modern, 19
anatomy of, 69
Endodontic therapy, gaining access to root
canal system in, 271272
success of, factors inuencing, 266
Endodontic working width, current
concepts and techniques, 323335
Endodontics, and microscope, 1118
cleaning and shaping techniques in,
323
conventional, failure of, and
retreatment, 265288
case selection for,
267271
reasons for, 265267

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S011-8532(04)00026-6

338

Index / Dent Clin N Am 48 (2004) 337339

Endodontics (continued )
retreatment versus
microsurgery, 267
removal of semisolid materials in,
275280
solid material removal in, 280286
Endodontics-only software, 311
G
Gutta percha, removal of, 275280
Gutta percha cones, obturation of root
canal system and, 204207, 211
of MicroSeal systems, 220, 221,
227231
Gutta percha heater, of MicroSeal systems,
221, 231232
I
Instruments, endodontic, nonsurgical
ultrasonic, 1934
for nonsurgical endodontics, 1314
K
K3 rotary nickel-titanium le system,
137157
authors experience with, 141143
clinical technique, 148156
assumptions for, 145148
les, 137, 138140
gauging of apex for, 154156
literature on, 143145
standard technique, variations on,
156157
L
LightSpeed System, 113135
instruments, design of, 113116
fracture of, 130
IAR, 119
maintenance and replacement of,
128130
MAR, 118, 119122
technique of, details of, 118127
principles of, 117118

description of, 221232


discussion of, 254263
gutta percha cones, 220, 221, 227231
gutta percha heater, 221, 231232
modications of, 224231, 237246
nickel-titanium nger and engine
spreader, 218, 223225
preclinical test, 232253
technique in, description of, 222, 223,
224, 232235
obturation, 218
Mineral trioxide aggregate, 6
in one-step apexication, 301302
to seal perforations, 291, 295296
Mouth mirror, for nonsurgical endodontics,
13
N
Nickel, allergies to, 59
Nickel-titanium nger and engine spreader,
of MicroSeal systems, 218, 223225
Nickel-titanium (NiTi), and stainless steel,
properties of, 55, 56
options and challenges in use of, 5567
use in endodontics, chronology of,
5964
Nickel-titanium (NiTi) alloy instruments,
corrosion and sterilization of, 5859
Nickel-titanium (NiTi) les, 56
common features of, 6162
composition of, 55, 56, 57
Nickel-titanium rotary instrumentation,
apical preparation for, 193197
body shaping for, 193
crown down, 188189
glide path for, 192193
hybrid concept of, 183202
limitations of, 199201
hybrid sequences overview in, 197
ideal preparation, 189190
master apical le size in, 191192
passive, representatives of, 185186
rules, 187
sample cases of, 197199
series 29 sizes, 185
step back, 189
straight line access for, 190
working length determination in, 190

M
Microscope, 13, 4
cost of, versus patient benet of, 18
endodontics and, 1118
in nonsurgical endodontics, 1118
procedures requiring, 1517

NiTi alloy instruments, manufacturing of,


5758

MicroSeal systems, 217264


condenser, 218, 219, 220, 224, 225227

NiTiNOL alloy, 55
manufacturing of, 5758

NiTi ProTaper system. See ProTaper NT


system.

Index / Dent Clin N Am 48 (2004) 337339


O
Obtura compactor, 5
Obturation, of root canal system. See Root
canal system, obturation of.
cavity preparation and, 217
Obturation instruments, 217219
Obturators, Thermal, 285
P
Patient education, computers for, 309
Positioning, for nonsurgical endodontics,
1213
Post, facilitated removal of, 272274
ProFile system, 6985
clinical applications and, 7680
eect of chloride and sterilization on,
73
le, clinical performance of, 7173
design of, 7071
retreatment using, 7980
safety concerns and, 7376
sequences for use of, 78, 79
ProTaper NT system, 87111
access cavity preparation with,
100101
design of instruments in, 8898
establishment of glide path with, 101
le(s), 9194
nishing, 9798
instrumentation with, 99108
shaping, 9597
irrigation and chelators used with,
102103
torque-controlled endodontic motors,
99100
R
Real World Endo Sequence File, 159182
le, cutting eciency of, 164165
design of, 167173
tip design in, 164
pitch/helical angles of, 171
resistance and torque
requirements, 165166
rotary, design of, 162167
exibility of, 166
quality of manufacturing, 163
speed of, 166167, 172173
technique of, 173175
for extrasmall canals, 175176
Root, perforation of, repair of, cases
illustrating, 296300
one-step apexication
procedures and,
291307

339

Root canal system, gaining access to, in


endodontic therapy, 271272
obturation of, 203215
cavity preparation and, 217
gutta percha cones and,
204207, 211
Obtura II unit and, 203, 205, 209
S-Kondensers and, 203, 204, 207,
208, 293294
System B unit and, 203, 204
to treat impossible cases, 212215
therapy of, calcium sulfate for
hemostasis and barrier in,
291293, 295
collatape for hemostasis and
barrier in, 291293
sodium hypochlorite for
irrigation in, 291
working width of, 324
at working length, determination
of, 327328
eliminating or minimizing
inuence of aecting
factors, 330332
factors aecting, 328330
minimal and maximal, at
working length,
determination of, 332333
Root perforation, electronic apex locator to
detect, 48
Rubber dam, placement for nonsurgical
endodontics, 1112
S
S-Kondensers, obturation of root canal
system and, 203, 204, 207, 208,
293294
Sodium hypochlorite, for irrigation in root
canal therapy, 291
System B/Touchn Heat, 2, 5
System B unit, obturation of root canal
system and, 203, 204
T
Thermal obturators, 285
Tips, ultrasonic. See Ultrasonic tips.
U
Ultrasonic instruments, 34
Ultrasonic tips, 34, 2023
access renement, 2427
bulk removal, 28
troughing, 2833
vibratory, 2728