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JOURNAL OF ENDODONTICS
COpyright 9 1985 by The American Association of Endodontists
An In Vitro Comparison of the Efficacy of the Step-
back Technique Versus a Step-back/Ultrasonic
Technique in Human Mandibular Molars
Comparacion In Vitro de la Eficacia de la Tecnica
Escalonada Versus la Tecnica Escalonada
Ultrasonica en Molares Inferiores de Humanos
Alan Goodman, DDS,MS, AI Reader, DDS,MS, Mike Beck, DDS,MA, Rudy Melfi, DDS,PhD,and
William Meyers, DMD,MEd
This study compared the effect of the step-back
preparation versus a step-back/ultrasound prepa-
ration on the tissue removal from the mesial root
canals of 60 extracted human mandibular molars.
rhe step-back/ultrasound preparation significantly
cleaned isthmuses at both levels and canals at the
1-mm level more effectively than the step-back
preparation. Statistical analysis indicated no signif-
icant difference, in canal cleanliness at the 3-mm
level, between the step-back and the step-back/
ultrasound groups. There were no significant differ-
ences demonstrated in isthmus cleaning ability
when comparing the step-back group with the con-
trol group, at both the 1- and 3-mm levels. At the 1-
mm level, operator 1 significantly cleaned canals in
the step-back group more effectively than operator
2. However, in the step-back/ultrasound group, no
significant differences were demonstrated between
operators in their ability to clean canals at this level.
In both experimental groups, operator comparisons
indicated no significant differences in isthmus
cleanliness at the 1-mm level.
Este estudio comparo el efecto de la preparacion
escalonada versus la preparacion escalonada por
ultrasonido en la remoci6n de tejido del conducto
de la raiz mesial de 60 molares humanos inferiores
extraidos. La preparacion escalonada por ultrason-
ido limpi6 los istmos en ambos niveles significati-
vamente y los conductos a un nivel de 1 mm mas
efectivamente que la preparacion escalonada. El
analisis estadistico no indico diferencias significa-
tivas en la limpieza del conducto a un nivel de 3 mm
entre los grupos de t(~cnica escalonada y tecnica
249
Printed in U.S.A.
VOL. 11, No. 6, JUNE1985
escalonada por ultrasonido. No se demostraron di-
ferencias significativas en la capacidad de limpieza
de los itstmos cuando se comparo el grupo de
tecnica escalonada con el grupo de control, tanto
en el nivel de 1 mm como en el de 3 mm. En el nivel
de 1 mm, el operador 1 limpio los conductos en el
grupo de tecnica escalonada en forma significati-
vamente mas efectiva que el operador 2. Sin em-
bargo, en el grupo de tecnica escalonada por ultra-
sonido, no se demostraron diferencias de importan-
cia entre los operadores en su capacidad de limpiar
los conductos a este nivel. En ambos grupos exper-
imentales, las comparaciones del operador no indi-
caron diferencias significativas en la limpieza de los
istmos en un nivel de 1 mm.
Complete tissue removal from the root canal system is
one of the major goals of successful endodontic therapy
(1,2). Proper debridement and shaping are necessary
for microbial control and adequate obturation (3, 4).
However, studies (5-7) of root canal anatomy have
shown the complexity of this system, which makes
complete debridement by mechanical means difficult.
The step-back (serialization, flaring) canal preparation
technique has been demonstrated to be the most ef-
fective debridement technique currently in use (8-10).
However, tissue and debris were found remaining
within the canal system even when utilizing this tech-
nique (8-10). There appears to be a definite need for
new techniques and materials to be developed and
investigated in an attempt to debride the root canal
system more completely.
250 Goodman et al.
Richman (11), in 1957, first reported on a technique
of root canal therapy using an ultrasonic instrument,
which he felt had important potentials for the future. In
a series of studies, Martin and his colleagues (12-19)
reported on the use of ultrasound as an intracanal
cleaning technique. They found that the root canals of
the teeth that were ultrasonically filed and irrigated,
when compared with conventional methods, were sig-
nificantly cleaner and the smear layer appeared to be
greatly reduced. Cameron (20) found that ultrasonics
was effective in removing the smear layer in biome-
chanically prepared teeth. Tauber et al. (21) found no
statistical difference between canals prepared with ul-
trasonics, hand filing, or ultrasonics with hand filing.
Cymerman et al. (22) reported no difference in debride-
ment between hand instrumentation and ultrasonic in-
strumentation. Weller et al. (23) quantitatively com-
pared the debridement efficacy of a hand-instrumented
serialization preparation, ultrasonic preparation, and a
hand-instrumented serialization preparation followed by
ultrasonics. They found that the most effective debride-
ment occurred when ultrasonication was used after
completion of hand instrumentation. These authors
concluded that ultrasonication was not an alternative
to conventional hand instrumentation, but it was a
significant aid in increasing the efficiency of endodontic
debridement.
Therefore, the purpose of this study was to compare,
histologically, the efficacy of the step-back preparation
versus a combined step-back/ultrasonic preparation in
the mesial root canals of extracted human mandibular
first and second molars.
MATERIALS AND METHODS
Freshly extracted, human first and second mandibu-
lar molars were collected and stored at 0~ until ready
for use. The age, sex, pulpal status, or reason for
extraction was not recorded. Radiographs were taken
of all teeth from the buccal direction and the degree of
curvature of each mesial root was determined using
Schneider's method (24). In order to standardize canal
curvature, only those roots exhibiting a 15 to 35 degree
of curvature were used in this study. Standard root
canal access openings were made using a # 4 round
bur, The presence or absence of coronal pulp tissue
was noted and recorded. Those teeth exhibiting no
pulp tissue were discarded from the study. The 60
remaining teeth were randomly divided into three
groups of 20 teeth,, with both mesial canals of each
root being treated alike according to the group. For
evaluation and standardization purposes, only those
mesial roots demonstrating a type 111 (25) canal con-
figuration were used in the study. This was verified,
during working length determination, when both file tips
were seen just protruding from two separate apical
foramens. All procedures involving canal preparation,
Journal of Endodontics
with the exceptions of working length determination,
were performed with the teeth stabilized in a modified,
bench-mounted cast metal vice. Customized rubber
pads were glued to the inner surface of the vice's
holding jaws to aid in stabilization and to prevent tooth
movement during the experimental procedure. The ex-
perimental teeth were randomly divided into two equal
groups, for preparation by two operators, in order to
evaluate any differences in operator technique. Follow-
ing working length determination, the entire filing pro-
cedure was performed utilizing a constant flow irriga-
tion/aspiration system. A 2.62% sodium hypochlorite
irrigating solution was placed in an elevated 2000-ml
pyrex flask, to which an angled 18-gauge, 11/2-inch
needle was connected via an intravenous extension set
(Travenol Labs., Inc., Deerfield, IL). The irrigation needle
was positioned next to a high-speed suction tip, which
provided a constant flow irrigation/aspiration system.
The gravity-propelled flow of irrigating solution was
calibrated, using the flo-trol clamp, to a rate of 40 ml/
rain.
A number 15 K-type file (Star Dental Mfg., Co., Valley
Forge, PA) was placed into the canal until the file tip
was just visible at the apical foramen. This length was
measured with an endodontic ruler and used as the
canal working length.
Step-back preparation (8-10), using an alternating
technique, was performed in the following sequence:
#15, 20, 25, and 30 (25 and 30 files were short of
working length); # 2 and 3 Gates Glidden. Alternating
sequence: #15, 35 (short of working length), 20, 40
(short), 25, 45 (short), 30, 50 (short); #5 Gates Glidden.
Step-back sequence: #35, 40, 45, 50. Final file (30F).
Each mesial root canal was enlarged approximately
three file sizes larger than the first file that bound in the
apical third of the canal. This corresponded to a #25
or 30 size file. Individual operator time of canal prepa-
ration was recorded for evaluation. Following comple-
tion of canal debridement and shaping, the irrigation/,
aspiration system remained functioning for an additional
period of 3 min/canal. After drying, each canal was
irrigated with 10% formalin to assure optimum fixation
of any remaining pulpal tissue.
The teeth in the step-back/ultrasonic group were
treated like those teeth in the step-back preparation
group except that an ultrasonically energized file was
used following completion of the step-back preparation.
The ultrasonic power source was Buffalo model S-40
Piezo Electric ultrasonic dental unit (Buffalo Dental
Mfg., Brooklyn, NY). This unit utilized a piezoelectric
ceramic rather than a magnetostrictive transducer (26-
28). The unit was operated at an automatically adjusted
frequency of 40,000 cycles/s. Since almost no heat
was generated, the unit could be operated without
using a coolant. A manually operated power control
knob, corresponding to a tip amplitude displacement
range of 0.001 to 0.004 inches, was set at the one-half
 Vol. 11, No. 6, June 1985
power setting and maintained at this position through-
out the experiment. To minimize cutting ability, a #15
tapered, finger plugger was used as the ultrasonic tip.
The T-4 ultrasonic scaling tip (Buffalo Dental Mfg.) was
modified by sectioning the triple-bended tip at its middle
bend, which produced a shortened unibend tip. A
groove was placed in the outer surface of the modified
tip to a depth just short of and running parallel to the
internal water channel. The plastic handle of the finger
plugger was removed, leaving an additional 5-mm
shank for soldering. The plugger was then positioned
within the groove and soldered to the ultrasonic tip
assembly using silver solder and the Torit Model 21-A
electric soldering machine (Torit Mfg. Co., St. Paul,
MN). After completion of the step-back preparation, the
ultrasonic file was used in an up and down, circumfer-
ential, brush-stroke motion. Prior to activation, the ul-
trasonic tip was placed into the canal until binding
occurred or working length was reached. This depth
was recorded on the instrument shaft with the use of
a silicone stop. In canals in which binding took place,
the stop was adjusted 1 mm short of this length which
indicated the maximum depth of instrument insertion
without binding in the canal. During a pilot study, the
silicone stop remained fixed in place during activation
of the ultrasonic instrument. However, ultrasonic acti-
vation frequently prevented insertion of the instrument
to the previously established depth of the inactivated
file. Therefore, after ultrasonic preparation, the rubber
stop was repositioned to the actual depth following
usage, remeasured, and recorded. The ultrasonic file
was used for a period of 3 min in each canal and at no
time was the instrument used at a depth beyond the
established working length. Irrigation was identical to
that used in the previous step-back group. After drying,
each canal was irrigated with 10% formalin.
The control teeth were opened and the presence of
pulp tissue was confirmed. These teeth were not in-
strumented and served as a control for the processing
and sectioning procedures.
At the conclusion of preparation, a single vertical
groove was placed in the mesial buccal root surface to
a depth of 0.5 mm. This groove was used as an aid in
determining canal identity during the processing and
evaluation procedures. Each tooth was placed into
COvered glass jars containing 10% formalin for a mini-
mum period of 48 h.
All teeth were decalcified and prepared for histologi-
cal sectioning. Seven-micrometer sections were ob-
tained using the Reichert-Jung 1140/Autocut micro-
tome (R-Jung, Heidelberg, West Germany) equipped
With a carborundium knife. All initial sections were
COllected and microscopically examined until verification
of the apical foramen occurred. Subsequent sections
Were numbered, with sections from the 1-mm (143rd
Section: _+4) and 3-mm (429th section: _+4) levels col-
lected for evaluation. Two technically error-free sec-
Step-beck Versus Step-back/Ultrasound 251
tions from each level were chosen blindly by an expe-
rienced histologist. One section was stained with he-
matoxylin and eosin and the other with Masson stain.
A total of 120 sections were used in this study for
evaluation. All mounted sections were projected on
white tracing paper using the Kramer Model XM Xenon
Microprojector (Kramer Scientific Corp., NY, NY) at a
magnification of • The slides were coded and
randomly projected so the evaluator was unaware of
the corresponding level or group. A black tracing pen
was used to outline each canal and isthmus wall. Pulpal
tissue debris was outlined with a red tracing pen. When
isthmuses were encountered, a blue tracing pen was
used to delineate the canal-isthmus interface. A com-
pensating polar planimeter, model 620005 (Keuffel &
Esser Co., Morristown, NJ), was used to determine the
area of each canal, isthmus, and remaining pulpal tis-
sue. The values were then calculated into percentage
of tissue removed. The collected raw data were ana-
lyzed nonparametrically utilizing the Kruskal-Wallis one-
way analysis of variance. A posteriori testing was done
using a nonparametric analogue to the Scheffe test.
Differences between operators were analyzed nonpar-
ametrically using the Mann-Whitney U test. Nonpara-
metric tests were used because of large differences in
the variances among most of the groups analyzed.
RESULTS
The mean values of percentage clean (canal and
isthmus) for each instrumentation technique, at each
level, are presented in Table 1. The comparisons be-
tween the canal groups are presented in Table 2. At
the 1-mm level, the step-back/ultrasound group (mean
value 97.3%) showed significantly greater canal clean-
liness than either the step-back group (mean value
91.3%) or control group (mean value 18.7%, p < 0.05).
There were also significant differences demonstrated
between the step-back group (mean value 91.3%) and
the control group (mean value 18.7%, p < 0.05). At the
3-mm level, the step-back group (mean value 98.9%)
and the step-back/ultrasound group (mean value
99.9%) showed significantly greater canal cleanliness
than the control group (mean value 27.6%, p < 0.05).
At this level, there were no significant differences be-
TAaLE 1. Summary of results for the three groups* at the 1- and
3-ram levels
Level No. of
Average % No. of Average %
Group (mm) Canals Clean/
Canal Isthmuses Clean/
Isthmus
1 1 40 91.33 9 21.67
1 3 40 98.98 10 37.26
2 1 40 97.29 8 72.03
2 3 40 99.97 10 92.03
3 1 30 18.69 4 19.85
3 3 31 27.61 7 3.41
* Group1, step-back;group2, step-back/ultrasound;group3, contr..
252 Goodman et al, Journal of EndodonticB

TABLE 2. Comparisons between the canal groups* at the 1- and cantly greater canal cleanliness than operator two (me-
3-mm levels dian value 93.2%, p < 0.05). However, in the step-
Level Kruskal-Wallis df p Group back/ultrasound group, at this level, there were no
(mm) Statistic Comparison P significant differences in canal cleanliness demonstra-
1 79.59 2 0.000 1 versus 2 <0.05 ted between operator one (median value 100.0%) and
1 versus 3 <0.05 operator two (median value 100.0%).
2 versus 3 <0.05
Isthmus cleanliness, in the step-back group, at the
3 84.70 2 0.000 1 versus 2 NS
1 versus 3 <0.05
1-mm level, showed no significant differences between
2 versus 3 <0.05 operator 1 (median value 19.8%) and operator 2 (me-
9Group1, step-back;group2, step-back/ultrasound;group3, control.
dian value 16.3%). Isthmus cleaniness, in the step-
back/ultrasound group, at this level, showed no signif-
TABLE 3. Comparisons between isthmus groups* at the 1- and
icant differences between operator 1 (median value
3-mm levels 86.1%) and operator 2 (median value 67.7%).
Level Kruskal-Wallis Group
(mm) Statistic df p Comparison P DISCUSSION
1 10.36 2 0,000 1 versus 2 <0.05 The results of this study showed that canals prepared
1 versus 3 NS
with the step-back/ultrasonic technique were signifi-
2 versus 3 <0.05
3 19.88 2 0.000 1 versus 2 <0.05 cantly cleaner than those in the step-back group. This
1 versus 3 NS finding can be attributed to the action of the ultrasoni-
2 versus 3 <0.05 cally activated irrigated solution within the canal sys-
* Group1, step-back;group2, step-back/ultrasound;group3, control. tem. When a chemical containing fluid medium, such
as sodium hypochlorite, is subjected to ultrasonic vibra-
TABLE 4. Operator mean and range of canal preparation time
tions, which produces cavitation, chemical activity is
utilizing only hand instruments* accelerated as a result of both mechanical and thermal
activity in the fluid (27). Most power ultrasonic proc-
Operator 1 Operator 2
Group (rain) (min) esses, involving liquids, utilize the phenomenon of cav-
itation as the action producing mechanism. This refers
1
Mean 11.3 13.6
to the growth and collapse of small bubbles in a liquid
Range 10-13 10-15 under the cyclic phases of rarefaction--compression
that occur during ultrasonic vibration. In any ordinary
Mean 9.9 13.2 liquid, bubble nuclei exist in the form of very small gas
Range 7-14 11-16 bubbles, dust particles, or other impurities. For given
* Group1, step-back;group2, step-back/ultrasound. conditions of frequency and alternating pressure level,
bubble nuclei of a critical radius will grow during the
tween the step-back group (mean value 98.9%) and rarefaction phase. During the compression phase, the
the step-back/ultrasound group (mean value 99.9%). bubble undergoes catastrophic collapse in a small frac-
The comparisons between the isthmus groups are tion of a vibration cycle. Extremely high pressures are
presented in Table 3. At the 1-mm level, the step-back/ thus instanteously developed and result in outward
ultrasound group (mean value 72.0%) showed signifi- propagating shock waves (28). Ewen (27) states that
cantly greater isthmus cleanliness than either the step- cavitation has a complex combination of characteris-
back group (mean value 21.7%) or control group (mean tics-mechanical, thermal, and chemical. Cavitation is
value 19.9%, p < 0.05). However, there were no sig- accompanied by sharp, but localized, increases in tem-
nificant differences between the step-back group (mean perature around the vapor bubbles. However, the over-
value 21.7%) and the control group (mean value all temperature of the fluid median is usually not sub-
19.9%). At the 3-mm ' level, the step-back/ultrasound stantially raised by this effect because of the relatively
group (mean value 92.0%) showed significantly greater
TABLE 5. Interoperator comparisons of canal and isthmuses
isthmus cleanliness than either the step-back group cleanliness at the l-ram level*
(mean value 37.3%) or control group (mean value 3.4%,
p < 0.05). However, there were no significant differ- Median % Clean:
Group Operator 1 U
ences between the step-back group (mean value versus Statistic P
37.3%) and the control group (mean value 3.4%). Operator 2
The mean and range of time comparisons between 1 (canal) 99.05 versus 93.20 124.5 <0.05
operators, in each experimental group, are presented 2 (canal) 100.00 versus 100.00 170.0 NS
in Table 4. Operator comparisons, at the 1-mm level, 1 (isthmus) 19.75 versus 16.30 7.0 NS
are presented in Table 5. In the step-back group, 2 (isthmus) 86.10 versus 67.70 6.5 NS
operator 'one (median value 99.0%) showed signifi- * Group1, step-back;group2, step-back/ultrasound.
 Vol. 11, No. 6, June 1985
low ratio of vapor bubbles to total fluid. Graft (28)
described other physical effects associated with ultra-
sound, in liquids, which are generally of lesser impor-
tance than cavitation but still play important roles in
ultrasonic technology. One such phenomenon is acous-
tic streaming, in which intense, local circulation and
vortex flow fields are observed near the vibrating trans-
ducer face. Such flow fields result from nonlinear fluid
behavior and can enhance the rates of heat and mass
transfer in the ultrasonic process.
In a pilot study, using ultrasonically energized K-type
files and diamond-coated files with a noncutting tip
(Abrasive Technology-Medical Inc., Columbus, OH), un-
controllable cutting and instrument fracturing were en-
countered. Cameron (29) reported using Hedstrom files
in a Cavitron ultrasonic insert. He found instrument
breakage was a problem, especially if the file was bent
to gain access to a posterior tooth. Therefore, a #15
ultrasonically energized finger plugger was used follow-
ing completion of the serial preparation with conven-
tional hand and rotary instruments, not for preparing or
shaping the canal, but for its ultrasonic activation of the
irrigating solution. The step-back preparation in the
step-back/ultrasonic group was utilized prior to ultra-
sonic cleaning to enhance debridement (23), to permit
a greater volume of fresh irrigating solution in contact
with the canal system (30, 31), and to make the canal
large enough for adequate obturation with gutta-percha
(4).
Baker et al. (30) reported that the removal of debris
and microorganisms from the root canal system
seemed to be a function of the quantity of irrigating
solution rather than the type of solution used. The
flushing action of the solutions, and not their tissue
dissolving qualities, appeared to be the significant fac-
tor. In the present study, even though a maximum
volume of fresh irrigating solution was utilized, the step-
back group, at the 1-mm level, was not as effectively
FIG 1. Photomicrograph of cross-section of mesiobuccal canal and
isthmus at the 1-mm level, group 1 (step-back). Mesiobuccal canal
demonstrating 68.9% cleanliness, with the isthmus 2.0% cleaned.
Masson stain; original magnification x31.
Step-back Versus Step-back/Ultrasound 253
FiG 2. Photomicrograph of cross-section of the mesial root at the l-
mm level, group 2 (step-back/ultrasonic). Mesiobuccal canal (/eft),
mesiolingual canal (right), and connecting isthmus demonstrating
100% cleanliness. Masson stain; original magnification x13.
cleaned as the step-back/ultrasonic group (Tables 1
and 2 and Figs. 1 and 2). This finding agrees with the
results reported by Weller et al. (23) in which ultrasonic
cleaning, following serial preparation, was significantly
more effective in removing radioactive-laden gelatin
than the serial technique alone.
At the 1-mm level, the canals prepared with the step-
back technique demonstrated an average of 91.33%
cleanliness per canal (Table 1). This result appears to
be greater than those reported in previous studies (8,
9), possibly due to the differences in the irrigating
solution and volume used. However, due to differences
in evaluation and statistical techniques, a true compar-
ison is not possible.
At the 3-mm level, there were no significant differ-
ences in canal cleanliness found between the step-back
and the step-back/ultrasonic groups (Table 2 and Figs.
3 and 4). Previous studies (8, 9) comparing the step-
back technique, reported canal cleanliness was en-
hanced at each level coronal to the root apex. This can
be attributed to a straighter canal found at the more
coronal levels of the root, resulting in more planed walls
(10). This would also yield a larger preparation with an
increase in volume of fresh irrigating solution contacting
the canal walls during instrumentation (30, 31). Cun-
ningham et al. (15) found that teeth prepared entirely
by ultrasonic instrumentation, at the 3-mm level, were
significantly cleaner than those prepared by a conven-
tional hand-filing technique. However, they used a con-
stant flow, high volume, irrigation/aspiration system in
conjunction with those teeth prepared with ultrasound,
whereas teeth prepared by conventional hand filing
were irrigated intermittently during canal preparation.
To eliminate the variable in canal cleanliness due to
unequal volumes of irrigating solution used, all experi-
mental teeth were prepared utilizing a high volume,
constant flow irrigation/aspiration system in this study.
254 Goodman et al.
FIG 3. Photomicrograph of cross-section of the mesiolingual canal
and isthmus at the 3-ram level, group 1 (step-back). Mesiolingual
canal demonstrating 99.3% cleanliness, with the isthmus 13.5%
cleaned. Masson stain; original magnification x20.
FIG 4. Photomicrograph of cross-section of the mesiolingual canal
and isthmus at the 3-mm level, group 2 (step-back/ultrasonic). Me-
siolingual canal demonstrating 100% cleanliness, with the isthmus
82.5% cleaned. Hematoxylin and eosin; original magnification x20.
The step-back/ultrasonic preparation significantly
cleaned isthmuses better than the step-back prepara-
tion, at both the 1- and 3-mm levels (Table 3 and Figs.
1 to 4). Apparently, t~e ultrasonically activated irrigating
solution penetrated areas of the canal system and
removed the pulpal tissue which hand instrumentation
left untouched.
Even when using at least forty times the volume of
irrigating solution as reported in previous studies (8, 9),
we found no significant differences in isthmus cleanli-
ness, at either level, when comparing the step-back
group with the noninstrumented control group (Table
3). As a result, areas of this variable and complex
system (5-7) which are not directly contacted by hand
instrumentation, regardless of the volume of irrigating
solution used, ap.pear to be unaltered by this method
of preparation (Figs. 1 and 3). This finding corroborates
Journal of Endodontics
the results reported by previous authors (8, 9), in which
isthmuses were determined to be inadequately cleaned,
even when prepared with the step-back technique.
Even though the step-back/ultrasonic preparation
was found to clean isthmuses and canals (1-mm level)
significantly better than the step-back preparation, tis-
sue debris was still found to some degree within these
teeth (Fig. 4). Therefore, none of the canal preparation
techniques used in this study were found to clean
consistently the canal system completely. A factor
which we believed might have accounted for this incom-
plete tissue removal was the inability to insert the
activated ultrasonic tip to the full working length in all
teeth. Of the 40 experimental canals in the step-back/
ultrasonic group, the average ultrasonic tip depth of
penetration was 2.7 mm short of the working length,
with a range of 0.0 to 5.0 mm. When initially placing
the inactivated ultrasonic tip in the canal, a deeper
penetration was achieved, compared with a "backing-
out" or withdrawing motion encountered when the tip
was activated. Both operators in this study reported
any canal irregularities, or curvatures, that became
ledged (minor) with the ultrasonic instrument prevented
further apical penetration of the activated tip. This
inability of complete canal penetration by the activated
ultrasonic tip can be attributed to the inherent flexibility
and physical properties of the finger plugger ultrasonic
tip design, and the ultrasonic power unit amplitude
setting. However, we found that in 31 of 40 canals in
which the ultrasonic tip did not negotiate to the full
working length, complete tissue removal was shown at
the 1-mm level. As a result, complete penetration of
the ultrasonic tip to the established working length
might not be necessary to obtain ultrasonic cleaning of
the apical levels.
FIG 5. Photomicrograph of cross-section of the mesial root at the 3-
mm level, group 2 (step-back/ultrasonic). Mesiobuccal canal (right),
mesiolingual canal (/eft), and connecting isthmus demonstrating
100% cleanliness. Note transposition of the mesiobuccal canal, re-
sulting in a near perforation of the root surface. Hematoxylin and
eosin; original magnification x8.
Vol. 11, No. 6, J u n e 1985
Even when using a smooth, noncutting, blunted tip
finger plugger as the ultrasonic instrument, cutting of
the canal wall was observed in 22 of the 40 canals. At
both the 1- and 3-mm levels, ultrasonic cutting resulted
in transposition (21 of 40 canals) (Fig. 5) and perforation
(1 of 40 canals) of the root surface, whereas 10 of 40
canals demonstrated transposition in the step-back
group, with no perforations observed. It may be that
this instrument system is too powerful for safe clinical
application. However, it did demonstrate remarkable
cleaning ability. Perhaps, further research with the com-
mercially available ultrasonic instruments can provide
an answer to the question of complete tissue removal
versus safe clinical use.
Operator one (99.05%) significantly cleaned the ca-
nals in the step-back group, at the 1-mm level, more
effectively than operator two (93.20%; Table 5). Even
though operator two consistently, in both groups, av-
eraged more time for canal preparation with hand in-
struments (13.4 min), resulting in an increased irrigating
volume and possibly a greater degree of planed walls,
the canals at this level were not as clean as those of
operator 1 (average time 10.6 min) (Table 4). This is in
agreement with Littman (32) who found that the differ-
ences in canal debridement where more dependent on
the operators than on the technique used. As shown in
Table 5, there were no significant differences found
between the operator's ability to clean the canals in the
step-back/ultrasonic group and the isthmuses in either
the step-back/ultrasonic preparation or step-back tech-
nique, at the 1-mm level. The ability of both operators
to clean canals and isthmuses equally in the step-back/
ultrasonic group could be due to the lack of individual
technique required to operate the ultrasonic instrument
effectively. Operation of the ultrasonic instrument is
more of a mechanical procedure, with the instrument
doing the actual work. However, a careful brushstroke
technique is still required. Forcing the instrument or
inappropriate planing may result in perforation in serially
prepared canals. Whereas in a hand-instrumented prep-
aration, the operator's technique appears to be an
important factor in cleaning efficiency (32). The use of
an ultrasonic instrument, following serial preparation
with hand instrumentation, might compensate for the
variable in operator technique, resulting in comparable
preparations.
It may be that complete tissue removal from the root
canal system will always be an enigma to the endodon-
tist, or further refinements in ultrasonic technology may
some day lead to 100% cleaning. We do want to
emphasize that the commercially available ultrasonic
instruments, and the studies supporting their use, are
not directly comparable to our results. Further studies
of amplitude settings versus time (how long the instru-
ment should be used) need to be done in order to find
the optimum cleaning ability of these instruments.
Step-back Versus Step-back/Ultrasound 255
SUMMARY
This study compared the effect of the step-back
preparation versus a step-back/ultrasonic preparation
on tissue removal from the mesial root canals of 60
extracted, human mandibular molars.
The teeth were randomly chosen and equally divided
into three groups. Twenty teeth were prepared with the
step-back technique utilizing K-type files and Gates
Glidden drills (group 1). Group 2 contained 20 teeth
prepared with the step-back technique followed by the
use of an ultrasonically energized, intracanal instru-
ment. Twenty teeth in group 3 were uninstrumented
and served as controls for the processing and section-
ing procedures. Both experimental groups were pre-
pared utilizing an equal volume, constant flow (40 ml/
min), irrigation/aspiration system of 2.62% sodium hy-
pochlorite solution. Following histological preparation,
sections were obtained from the apical 1- and 3-mm
levels and projected on a screen. Tracings were then
made outlining each canal, isthmus, and any remaining
pulpal tissue. The percentage of tissue removed within
each canal and isthmus was measured and recorded
using a compensating polar planimeter.
The step-back/ultrasonic preparation significantly
cleaned isthmuses at both levels and canals at the 1-
mm level more effectively than the step-back prepara-
tion. Statistical analysis indicated no significant differ-
ence, in canal cleanliness at the 3-mm level, between
the step-back and the step-back/ultrasonic groups.
There were no significant differences demonstrated in
isthmus cleaning ability when comparing the step-back
group with the control group, at both the 1- and 3-ram
levels. At the 1-mm level, operator 1 significantly
cleaned canals in the step-back group more effectively
than operator 2. However, in the step-back/ultrasonic
group, no significant differences were demonstrated
between operators in their ability to clean canals at this
level. In both experimental groups, operator compari-
sons indicated no significant differences in isthmus
cleanliness at the 1-mm level.
This study was supported by research funding from the Ohio Association
of Endodontists.
This article was adapted from a thesis submitted by Dr. Goodman in partial
fulfillment of the requirements for the MS degree at Ohio State University,
Columbus, OH. A portion of this article was presented at the 41st Annual
American Association of Endodontists meeting, Toronto, Canada, and was
honored by a graduate student research award.
Dr. Goodman is in private practice limited to endodontics, Atlanta, GA. Dr.
Reader is associate professor, Department of Endodontics, Ohio State Univer-
sity, Columbus, OH. Dr. Beck is associate professor, Department of Oral
Diagnosis, Oral Medicine, Ohio State University. Dr. Melfi is professor and
assistant dean, Department of Oral Biology, Ohio State University. Dr. Meyers
is professor and chairman, Department of Endodontics, Ohio State University.
Address requests for reprints to Dr. Reader, Department of Endodontics,
College of Dentistry, Ohio State University, 305 W. 12th Ave., Columbus, OH
43210.
256 Goodman et al.
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