BASIC RESEARCH – TECHNOLOGY

Airton Oliveira Santos-Junior,

New Ultrasonic Tip Decreases DDS, MSc, Mario Tanomaru-
Filho, DDS, PhD,
Uninstrumented Surface and Jader Camilo Pinto, DDS, MSc,
Karina Ines Medina Carita
Debris in Flattened Canals: Tavares, DDS, MSc,
Mariana Mena Barreto Pivoto-
A Micro–computed Joa~o, DDS, PhD, and
Juliane Maria Guerreiro-
Tomographic Study Tanomaru, DDS, PhD

ABSTRACT
SIGNIFICANCE
Introduction: The preparation of flattened root canals using reciprocating or rotary nickel-
titanium instruments associated with the Flatsonic ultrasonic tip (Helse Ultrasonic, Santa Rosa The presence of
de Viterbo, SP, Brazil) was evaluated by micro–computed tomographic imaging. uninstrumented surface and
Methods: Twenty-four flattened distal canals of mandibular molars with a buccolingual debris after the preparation of
diameter 4 or more times larger than the mesiodistal diameter were selected. The root canals flattened canals is related to
were randomly divided into 2 experimental groups for preparation: a Reciproc Blue (RB; VDW the failure of endodontic
GmbH, Munich, Germany) 40/.06 file in reciprocating motion or ProDesign Logic (PDL; Easy treatment. The association of
Equipamentos Odontolo
gicos, Belo Horizonte, MG, Brazil) 40/.01 and 40/.05 files in rotary NiTi instruments with a new
motion (n 5 12). A complementary preparation was performed with the Flatsonic ultrasonic tip ultrasonic tip is an effective
for both preparations. Micro–computed tomographic scanning at a resolution of 8.74 mm was protocol for the preparation of
performed before and after preparation with the nickel-titanium instruments and after the use flattened canals.
of the Flatsonic tip. The percentages of increase in volume, debris, and uninstrumented
surface were analyzed. The data obtained were submitted to the paired and unpaired t test,
analysis of variance, and the Tukey test (a 5 5%). Results: The percentage increase in
volume, debris, and uninstrumented surface was similar between RB and PDL in the entire
root canal (P . .05). The PDL promoted a lower percentage of debris in the cervical third and a
lower percentage of increase in volume in the apical third in comparison with RB (P , .05). The
Flatsonic decreased debris and uninstrumented surface after PDL preparation in all thirds (P ,
.05). After preparation with RB, the Flatsonic decreases the debris in the cervical third and the
uninstrumented surface in the cervical and middle thirds (P , .05). Conclusions: The
preparation of flattened root canals using RB or PDL produced a high percentage of debris
and uninstrumented surface. The Flatsonic ultrasonic tip significantly improved the cleaning of
flattened root canals. (J Endod 2020;-:1–7.)

KEY WORDS
Micro–computed tomography; nickel-titanium; root canal preparation; ultrasonics From the Department of Restorative
~o Paulo State University,
Dentistry, Sa
School of Dentistry, Araraquara, S~ao
Flattening of the root canal is the main challenges related to cleaning during root canal preparation1. After
Paulo, Brazil
preparation using nickel-titanium (NiTi) instruments, considerable percentages of uninstrumented walls
Address requests for reprints to Dr Mario
have been observed in oval2 and flattened canals1,3. The uninstrumented surface contains debris and
Tanomaru-Filho, Department of
bacterial biofilm4,5 and may lead to endodontic therapy failure3,6. Restorative Dentistry, Araraquara Dental
No mechanized NiTi system is effective on all root canal walls2,7,8. The centric position of School, S~ao Paulo State University, Rua
instruments during preparation allows debris and infected dentin to remain in flattened areas9,10. Humaita
, 1680, CEP, 14801-903,
However, the action of an ultrasonic tip has been shown to significantly improve disinfection in flattened Araraquara, SP, Brazil.
E-mail address: tanomaru@uol.com.br
canals5 and cleaning in the retreatment of flattened root canals11. Ultrasonic tips with mechanical action in 0099-2399/$ - see front matter
preparation12 and retreatment of oval canals13 can promote proper cleaning of the root canals.
Copyright © 2020 American Association
Reciproc Blue (RB; VDW GmbH, Munich, Germany) is a single-file NiTi instrument used in of Endodontists.
reciprocating motion that presents morphologic characteristics similar to Reciproc files. However, RB is https://doi.org/10.1016/
made with Blue-Wire treatment that improves its flexibility and increases its resistance to cyclic j.joen.2020.07.012

JOE  Volume -, Number -, - 2020 Uninstrumented Surface and Debris in Flattened Canals 1
fatigue14,15. RB has a similar ability for root
canal preparation as Reciproc15. In addition,
this instrument was effective in removing filling
material and reducing bacteria in oval root
canals16,17. ProDesign Logic (PDL; Easy
Equipamentos Odontolo
gicos, Belo Horizonte,
MG, Brazil) is a rotary NiTi instrument system
with a glide path instrument (taper .01) and
instruments for root canal preparation (taper
.03, .04, .05, or .06). The controlled memory
heat treatment applied to PDL allows greater
flexibility, providing higher centralization ability
in curved root canal preparation18. Although
PDL promoted less rounded root canal
preparation than ProTaper Next (Dentsply
Maillefer, Ballaigues, Switzerland) and
WaveOne Gold (Dentsply Maillefer)19, the
preparation of long oval canals using PDL is
safe and fast20.
Recently, the ultrasonic tip Flatsonic
(Helse Ultrasonic, Santa Rosa de Viterbo, SP,
Brazil) was proposed for the preparation and
retreatment of flattened root canals. Flatsonic
is made of stainless steel and has a tip
diameter of 0.25 mm, a flat inverted arrow
design, and a smooth surface. Up until now,
there are no studies evaluating the
performance of this tip used as an auxiliary
method in the preparation of flattened root
canals. Thus, the aim of this study was to
evaluate the root canal increase, debris, and
uninstrumented surface after preparation with
RB 40/.06 or PDL 40/.01 and 40/.05 files in
association with the Flatsonic ultrasonic tip in
flattened root canals. The first null hypothesis
tested was that there would be no difference in
the capacity for preparing flattened canals
between the RB and PDL systems. The
second null hypothesis was that Flatsonic
would have no influence on the percentage of
debris and uninstrumented surface in flattened
root canals.
MATERIALS AND METHODS
The tests were performed with G* Power
software (3.1.7 for Windows; Heinrich Heine
€sseldorf, Du
Universit€at Du €sseldorf, Germany).
The t test for 2 independent groups was used
with an alpha-type error of 0.05 and a beta
power of 0.80 for all of the variables. Previous
studies were used to determine the following
specific effect for each variable: percentage of
increase in volume (50.9779)1, debris
(51.2635)8, and uninstrumented surface
(51.3909)8. A total of 12 specimens per group
was indicated as being the ideal size required.
After approval by the ethics committee
(CEP no. 98683818.0.0000.5416), 24 distal
canals of mandibular molars were selected
using a digital radiographic system (RVG 6100;
Kodak Dental Systems, Rochester, NY) and
2 Santos-Junior et al.
micro–computed tomographic (micro-CT)
imaging (SkyScan 1176; Bruker-microCT,
Kontich, Belgium). Scanning was performed
with a voxel size of 35 mm with the following
parameters: a copper and aluminum filter,
exposure time of 87 milliseconds, frame
averaging of 3, rotation of 180 , rotation step
of 0.5, 80 kV, and 300 mA.
The roots canals selected had a type I
configuration according to the Vertucci
classification21 and the presence of flattening
in which the diameter ratio was obtained when
the buccolingual distance was 4 or more times
larger than that of the mesiodistal diameter22 at
a distance of 9 mm from the radiographic
apex23. Teeth with caries, previous endodontic
treatment, fracture, restorations, resorption, or
an open apex were excluded. The teeth were
divided into 2 experimental groups (n 5 12)
with stratified random sampling, considering
the preoperative volume of the root canals.
Root Canal Preparation
Conventional access cavities were prepared,
and the canals were explored using a size #10
K-file (Dentsply Sirona, Ballaigues,
Switzerland). When the tip of the instrument
was visible through the main foramen, 1.0 mm
was subtracted to determine the working
length (WL). An endodontic specialist prepared
all the teeth with the aid of a dental operating
microscope (DF Vasconcellos, Valença, RJ,
Brazil) at !13 magnification.
The RB 40/.06 file was operated by an
electric motor (VDW SILVER; VDW GmbH,
Munich, Germany) set in the “RECIPROC ALL”
function in accordance with the
manufacturer’s instructions. Each instrument
was gradually inserted into the canal in in-and-
out movements at the 3 levels (cervical, middle,
and apical) up to the WL. After RB attained the
WL, 2 brushing movements were performed
against the vestibular and lingual walls.
The PDL 40/.01 file was operated by an
electric motor (VDW SILVER) in rotary motion
at a speed of 350 rpm and torque of 1 Ncm
FIGURE 1 – Images of the Flatsonic ultrasonic tip obtained by a digital inverted microscope. (A ) A front view of the tip
showing the reduced diameter. (B ) A lateral view of the tip showing the inverted flattened arrow design.
with in-and-out movements up to the WL.
Then, PDL 40/.05 was used at 950 rpm and
torque of 4 Ncm as described previously. After
PDL 40/.05 attained the WL, 2 brushing
movements were performed against the
vestibular and lingual walls.
The root canals were irrigated with 5 mL
2.5% sodium hypochlorite (NaOCl) using a
NaviTip 30-G needle (Ultradent, South Jordan,
UT) adapted to a 5-mL syringe placed up to 2
mm short of the WL. After irrigation with 2.5%
NaOCl, the root canals were dried with
capillary tips. Then, 2 mL 17% EDTA and 5 mL
saline were used. The root canals were
aspirated with capillary tips and dried with
absorbent paper tips (Dentsply Sirona).
The Flatsonic tip (Fig. 1A and B) was
activated in all of the canals for 15 seconds in
the direction of each region flattening (buccal
and lingual), 10 seconds without air/water
cooling and 5 seconds with air/water cooling.
This protocol was repeated 3 times. For each
ultrasound cycle, 3 mL 2.5% NaOCl was used
(1.5 mL before and 1.5 mL after each cycle). To
activate the Flatsonic, an ultrasonic device
(Ultrawave XS, Ultradent) was used at a power
of 25% and a frequency of 50 Hz. Final
irrigation after use of the ultrasonic tip was
performed in accordance with the criteria
described in the preparation with NiTi.
Micro-CT Scanning
The specimens were scanned before and after
preparation with the NiTi instruments and after
the use of the ultrasonic tip. The parameters
used were 80 kV, 300 mA, a rotation step of
0.5, rotation of 180 , frame averaging of 4, a
copper and aluminum filter, an exposure time
of 2000 milliseconds, and a voxel size of 8.74
mm. The data sets obtained were
reconstructed with the use of NRecon
software (v.1.6.3, Bruker-microCT). For
superimposition, we used the “3D registration”
function of the Data Viewer software (v.1.5.1,
Bruker-microCT). The images were
analyzed using CTAn software (v.1.14.4,
JOE  Volume -, Number -, - 2020
TABLE 1 - The Means 6 Standard Deviation of Pre- and Postpreparation Volume (mm3), Increase in Volume (%),
Debris (%), and Uninstrumented Surface (%) of Flattened Distal Canals of Mandibular Molars Prepared with Reciproc
% uninstrumented
Blue or ProDesign Logic
uninstrumented surface!100
surface 5
Reciproc Blue ProDesign Logic final surface
40/.06 40/.01 and 40/.05
Before preparation (mm3)
Total 5.7784 6 1.5734a 6.0735 6 2.6735a
Cervical 2.9343 6 0.7493aA 3.2988 6 1.5163aA
Middle 1.9692 6 0.5138aB 2.1832 6 0.9681aB Statistical Analysis
Apical 0.8625 6 0.2641aC 0.9388 6 0.6401aC The data were submitted to the Shapiro-Wilk
Preparation (mm3) normality test. The nonpaired t test was used
Total 7.6363 6 1.7270a 9.0189 6 2.2007a for comparison between groups. For
Cervical 3.9246 6 0.9797aA 4.8866 6 1.7289aA comparisons between the thirds of each
Middle 2.6210 6 0.7296aB 2.8296 6 1.1087aB group, analysis of variance and Tukey tests
Apical 1.1224 6 0.2639aC 1.3991 6 0.5784aC were used. The paired t test was used for
Increase in volume (%)
comparisons with the same groups before and
Total 41.3005 6 13.3900a 45.1046 6 18.3136a
after use of the ultrasonic tip. The level of
Cervical 34.5047 6 17.2047aA 45.8751 6 8.8968aA
Middle 49.6773 6 16.0554aA 36.6725 6 18.7261aA significance was 5% for all analyses.
Apical 54.1879 6 20.6301aA 41.4788 6 24.0506bA
Debris (%)
Total 9.4095 6 3.7660a 5.7660 6 2.9007a
RESULTS
Cervical 12.0644 6 5.6357aA 5.7593 6 4.5207bA The percentage increase in volume, debris,
Middle 4.1701 6 2.5259aB 5.0396 6 2.9390aA and uninstrumented surface was similar
Apical 4.2202 6 2.0593aB 4.5292 6 3.0189aA between RB and PDL in the entire canals (P .
Uninstrumented surface (%)
.05). PDL showed a lower percentage of debris
Total 49.4194 6 27.5143a 52.0723 6 16.5518a
in the cervical third in comparison with RB (P ,
Cervical 52.0611 6 26.9610aA 50.7454 6 17.3238aA
Middle 41.0523 6 20.4552aA 46.5298 6 24.2541aA .05). RB produced a higher percentage
Apical 39.0572 6 23.8615aA 47.8075 6 22.6888aA increase in volume in the apical third in
comparison with PDL (P , .05). RB produced
Different superscript lowercase letters in the same line indicate a statistical difference between the groups (P , .05). a higher percentage debris accumulation in the
Different superscript capital letters in the same column indicate a statistical difference among the thirds of the same groups
cervical third in comparison with the middle
for each analysis (P , .05).
and apical thirds (P , .05) (Table 1).
The Flatsonic tip diminished the debris
Bruker-microCT), and tridimensional images uninstrumented surface) were calculated using and uninstrumented surface values after
were made using CTVox software (v.3.2, the following formulas7,24: preparation with PDL in the entire canal and
Bruker-microCT).  2100 in all thirds (P , .05). After preparation with
The initial volume, final volume, and final final volume!100 RB, Flatsonic diminished the uninstrumented
% volumetric increase 5
surface after preparation were obtained. initial volume surface value in the canal as a whole and in
Based on these values, the percentage of the cervical and middle thirds (P , .05). The
volumetric increase (% volumetric increase), percentage of debris in the middle and
the percentage of debris (% debris), and the apical thirds was similar in the canals
volume of debris!100
percentage of uninstrumented surface (% % debris 5 prepared with RB before and after the use
final volume
of Flatsonic (P . .05) (Tables 2 and 3 and
Figs. 2 and 3).

TABLE 2 - The Mean 6 Standard Deviation of Debris (% and mm3) of Flattened Distal Canals of Mandibular Molars Prepared with Reciproc Blue or ProDesign Logic before and after
Preparation with Flatsonic Ultrasonic Tip

Debris (%) Debris (mm3)

Before Flatsonic After Flatsonic Before Flatsonic After Flatsonic Reduction in debris (%)
Reciproc Blue
Total 9.4095 6 3.7660a 2.4024 6 1.2948b 0.7494 6 0.3705a 0.2478 6 0.1054b 66.93
Cervical 12.0644 6 5.6357a 1.9203 6 0.8230b 0.5747 6 0.2891a 0.1046 6 0.0510b 82.00
Middle 4.1701 6 2.5259a 2.6543 6 0.9748a 0.1690 6 0.0543a 0.1141 6 0.0632a 31.25
Apical 4.2202 6 2.0593a 3.2556 6 2.8239a 0.0947 6 0.0025a 0.0657 6 0.0397a 34.75
ProDesign Logic
Total 5.7660 6 2.9007a 1.4910 6 0.6421b 0.6394 6 0.3297a 0.1698 6 0.0832b 73.44
Cervical 5.7593 6 4.5207a 1.1403 6 0.4093b 0.3270 6 0.1815a 0.0877 6 0.0225b 73.18
Middle 5.0396 6 2.9390a 1.2645 6 0.3628b 0.2190 6 0.1657a 0.0455 6 0.0270b 79.33
Apical 4.5292 6 3.0189a 2.3508 6 1.0700b 0.0998 6 0.0446a 0.0475 6 0.0203b 52.40

Different superscript lowercase letters in the same line indicate a statistical difference within groups in different times (P , .05).

JOE  Volume -, Number -, - 2020 Uninstrumented Surface and Debris in Flattened Canals 3
TABLE 3 - The Mean 6 Standard Deviation of Uninstrumented Surface (% and mm2) of Flattened Distal Canals of Mandibular Molars Prepared with Reciproc Blue or ProDesign Logic
before and after Preparation with Flatsonic Ultrasonic Tip

Uninstrumented surface (%) Uninstrumented surface (mm2)

Reduction in uninstrumented
Before Flatsonic After Flatsonic Before Flatsonic After Flatsonic surface (%)
Reciproc Blue
Total 49.4194 6 27.5143a 24.1680 6 5.4688b 65.6684 6 34.4583a 14.4816 6 5.6130b 78.46
Cervical 52.0611 6 26.9610a 19.0350 6 8.0233b 51.0071 6 27.9252a 5.6308 6 2.5580b 90.19
Middle 41.0523 6 20.4552a 23.8943 6 8.3990b 10.7534 6 5.6614a 5.5089 6 2.9589b 47.32
Apical 39.0572 6 23.8615a 28.2626 6 12.6191a 4.1650 6 2.6754a 3.3881 6 1.4877a 18.21
ProDesign Logic
Total 52.0723 6 16.5518a 21.5113 6 14.9970b 58.4690 6 23.5775a 14.5808 6 7.1030b 75.05
Cervical 50.7454 6 17.3238a 17.3340 6 15.9848b 33.5130 6 13.3896a 6.5368 6 2.5910b 80.60
Middle 46.5298 6 24.2541a 19.3454 6 13.5743b 18.0315 6 6.3195a 3.9374 6 1.7220b 78.40
Apical 47.8075 6 22.6880a 26.0831 6 11.5496b 7.1535 6 2.5867a 3.5966 6 1.0793b 49.79

Different superscript lowercase letters in the same line indicate a statistical difference within groups in different times (P , .05).

DISCUSSION
One of the main limitations of root canal
preparation studies using micro-CT imaging in
extracted teeth is the selection of specimens25.
In this study, the initial selection of teeth was
performed using micro-CT imaging at a
resolution of 35 mm. In the present study, the
distal root canals of mandibular molars were
used because they have a considerable
percentage of flattening, approximately
20.25%26. The first null hypothesis was
partially accepted; the percentage increase in
FIGURE 2 – Three-dimensional reconstructions and cross-sectional views of the cervical (C), middle (M), and apical (A)
thirds of 2 representative flattened distal canals of mandibular molars prepared by RB and PDL before and after
preparation with the Flatsonic tip. The uninstrumented surface is in red, and the instrumented surface is in green.
volume, debris, and uninstrumented surface
was similar between the RB reciprocating
system and the PDL rotary system in the entire
canal. Different studies have demonstrated
similarity in the preparation capacity between
reciprocating and rotary instrumentation7,19,27.
However, RB showed greater accumulation of
debris in the cervical third in comparison with
PDL. The kinematics and number of
instruments may influence the preparation of
the root canal8. Moreover, during the brushing
motion, the greater flexibility of PDL may have
favored the effect in the flattened cervical
areas. The controlled memory heat treatment
of the PDL instruments promotes greater
flexibility than the Blue-Wire treatment of RB28.
A previous study observed that multiple rotary
instruments for preparation in canals with a
high prevalence of isthmuses and protrusions
produced cleaner canals with less
accumulation of debris in comparison with
single reciprocating instruments29. However,
both preparations resulted in a high
percentage of debris and uninstrumented
surfaces. Different studies have reported a
considerable percentage of uninstrumented
surface in oval7,8,12 and flattened1,3 canals.
RB showed greater accumulation of
debris in the cervical third in comparison with
the other thirds. Because the flattened regions
favor the accumulation of debris, the trend
toward a larger extent of flattening in the
cervical region may have contributed to these
results26. The PDL system showed a lower
percentage increase in volume in the apical
third in comparison with RB. This may be
explained by the difference in taper between
the instruments. RB has a 0.06 taper in the
apical 3 mm and PDL a 0.05 taper. Although
RB has promoted a greater increase in volume
in the apical third, it does not indicate that
dentin removal occurred in the entire flattened
area of the root canal8. The greater increase in
root canal volume is not necessarily associated
with less uninstrumented surface8,20,24.
The second null hypothesis was
rejected because the Flatsonic ultrasonic tip
significantly reduced the percentage of debris
and uninstrumented surface after the use of
RB or PDL. A previous study that evaluated the
use of the Flatsonic tip in oval canals observed
lower uninstrumented surface when root canal
preparation was performed by the association
of rotary instruments and ultrasonic tips12. The
anatomic flattened inverted arrow design of the
Flatsonic tip allows one to reach the

4 Santos-Junior et al. JOE  Volume -, Number -, - 2020


FIGURE 3 – Three-dimensional reconstructions of 2 representative flattened distal canals of mandibular molars
prepared by RB and PDL (A ) before and (B ) after preparation with the Flatsonic tip. Before Flatsonic is in red, after
Flatsonic in green, and debris in black.
buccolingual extension. The 0.25 mm diameter
Flatsonic tip favored cleaning of the canals with
a larger flattened extension12. The enhanced
effect of the Flatsonic tip possibly occurs by
the association of physical and mechanical
action. Flatsonic has mechanical action by
removing dentin in the flattened areas where
the NiTi instruments were unable to reach,
improving penetration of the irrigating solution.
Ultrasonic tips are widely used in the
retrograde cavity preparation, allowing proper
cavity preparation according to the long axis of
JOE  Volume -, Number -, - 2020
Reciproc followed by the use of the Clearsonic
ultrasonic tip promoted a greater reduction of
the uninstrumented surface than Reciproc R40
associated with brushing movements;
however, both groups showed similar
accumulation of debris32. The root canal
preparation can influence the effect of the
Flatsonic in flattened areas12 because the
Flatsonic tip significantly decreased debris and
uninstrumented surface in all thirds after
preparation with PDL. The smaller diameter of
PDL may have favored the contact with the
flattening areas during the brushing
movement, improving the effectiveness of the
Flatsonic tip. Instruments with smaller
diameters may present better access to
flattening root canal areas7.
The 0.25 mm diameter Flatsonic tip
appeared to be effective for cleaning the
flattened areas of the root canals. The
combination of mechanized NiTi instruments
associated with ultrasonic tips in the preparation
of flattened canals must be encouraged.
CONCLUSIONS
The preparation of flattened root canals with
NiTi instruments left a high percentage of
debris and uninstrumented surface
irrespective of the system used. The Flatsonic
tip significantly improved the cleaning process
when used as a complementary means of
preparation flattened root canals.
the root canal30. Moreover, the physical
ultrasonic effect on the irrigating solution
ACKNOWLEDGMENTS
provides a continuous flow favoring the Supported by Coordenaça ~o de
removal of debris. The energy transmitted by Aperfeiçoamento de Pessoal de Nível Superior
the generated ultrasonic waves can remove (financial code 001), Conselho Nacional de
dentin debris, microorganisms, and organic Desenvolvimento Científico e Tecnolo
gico
tissues from the root canal31. (grant nos. 133310/2018-3 and 307145/
Flatsonic did not significantly decrease 2015-8), and Fapesp - Sa ~o Paulo Research
debris in the middle and apical thirds and Foundation (grant nos. 2017/14305-9 and
uninstrumented surface in the apical third after 2017/19049-0).
preparation using RB. A recent study showed The authors deny any conflicts of
that the preparation of long oval canals with interest related to this study.
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