Case Report/Clinical Techniques
Negotiability of Second Mesiobuccal Canals in Maxillary
Molars Using a Reciprocating System
Mario Luis Zuolo, DDS, MSc,* Maria Cristina Carvalho, DDS, MSc, PhD,*
and Gustavo De-Deus, DDS, MSc, PhD†
Abstract
The aim of this prospective case series report was to
assess the frequency in which the Reciproc R25 instru-
ment (VDW, Munich, Germany) is able to scout
and reach the full working length (WL) in second
mesiobuccal (MB2) canals from maxillary molars.
Conventional hand file negotiation was used as the
reference technique for comparison. Maxillary molars
K nowledge of root canal anatomy is essential to achieve proper cleaning and shaping
(270 first molars and 71 second molars) were included
in this study. After local anesthesia, the tooth was iso-
lated with a rubber dam, and traditional straight-line ac-
cess was made. After locating both first mesiobuccal
and MB2 canals, patients were randomly assigned to
one of the experimental groups (conventional hand fil-
ing preparation or R25 Reciproc preparation). All cases
in which the hand files (G1) and R25 instrument (G2)
were able to reach the fully electronically determined
WL were classified as ‘‘reaching full WL’’ (RFWL). All
cases in which the hand files (G1) and R25 instrument
(G2) were unable to negotiate the full-length canal
were classified as ‘‘not reaching full WL’’ (NRFWL).
The number of root canals classified as RFWL and
NRFWL from both groups were recorded and tabulated
on an Excel data sheet (Microsoft, Redmond,
WA). The frequency distributions (%) of root
canals classified as RFWL and NRFWL were compared
with overall-treated canals and for each treatment
approach (hand file and R25 instrument) using a Pear-
son chi-square test. In group 1, the hand file approach
reached the full WL in 57.48% of cases, whereas in
group 2 the R25 instrument reached the full WL in
85.63% of cases. Three file separations occurred in
each group while negotiating the MB2 canal. According
to this study, the R25 instrument was 32% more effec-
tive when compared with hand files in scouting and
negotiating MB2 canals in maxillary first and second
molars. There was no difference with regard to file sep-
aration when comparing both preparation techniques.
(J Endod 2015;41:1913–1917)
From the *Department of Restorative Dentistry, Endodontic Division, Piracicaba Dental School, State University of Campinas, Piracicaba; and †Department of End-
odontics, Grande Rio University, Rio de Janeiro, Rio de Janeiro, Brazil.
Address requests for reprints to Prof Gustavo De-Deus, Av Henrique Dodsworth, 85, Apto 808, Lagoa, Rio de Janeiro, RJ 22061-030, Brazil. E-mail address: endogus@
gmail.com
0099-2399/$ - see front matter
Copyright ª 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.08.004
JOE — Volume 41, Number 11, November 2015
Key Words
Negotiation, Reciproc, reciprocating motion, root canal preparation, rotary system,
scout, second mesiobuccal canal
procedures. An adequate understanding of the overall configuration of the pulp
space and its typical variations allows the clinician to successfully locate, scout, enlarge,
and disinfect all the root canals (1). The first maxillary molar is the bulkiest tooth in the
mouth presenting many anatomic variations. In most cases, distobuccal and palatal
roots have a single canal; however, the mesiobuccal root usually shows more anatomic
variations in terms of number, position, and canal configuration. Therefore, the loca-
tion of the second mesiobuccal (MB2) canal is a challenging task, which may cause
important repercussions on the long-term treatment outcome. Moreover, it is note-
worthy that the second canal is reported to be present in, as often as, 96% of the times
in the mesiobuccal root of first maxillary molars (2, 3).
Once the canal orifice is located, another challenge faced by the clinicians is to
scout and negotiate this narrow, curved, and intricate root canal. The MB2 canals usu-
ally have a dentin ledge that often covers the canal orifice because of the mesiobuccal
inclination toward the pulpal floor. Additionally, calcifications (4) and single or double
abrupt curvatures in the coronal middle thirds of the canal render scouting and nego-
tiating a difficult and time-consuming task (5). Although there is evidence showing that
the MB2 canals are present in 96% of the maxillary molars, only less than 80% could be
successfully negotiated by the conventional technique using small hand files, even when
using the operating microscope (6). Clinically, a considerable number of MB2 canals
are indeed unable to be scouted, negotiated, and treated properly by traditional tech-
niques.
In 2008, a new concept of using only 1 specially designed nickel-titanium (NiTi)
instrument driven in an asymmetric reciprocating movement was introduced (7, 8). In
short, asymmetric reciprocation can be defined as the sequence of repetitive and
imbalanced back-and-forth rotational movement, which somehow mimics the balanced
force hand filing motion (9). Rotation angles are unequal and lower, thus remaining
under the plastic limit of the instrument. As a result, torsional stress is reduced, and
safety is improved (10, 11). Furthermore, a feature of great importance for the
reciprocating-based instrumentation is its efficiency in negotiating the root canals; usu-
ally, the instrument is able to smoothly advance toward the apex compared with contin-
uous rotation. In fact, 1 interesting feature of the reciprocating system (Reciproc
System; VDW, Munich, Germany) is its ability to prepare most root canals with no pre-
vious hand filing (8). This efficient inward advance of the instrument into the canal
space has raised new perspectives for mechanical preparation. Therefore, the aim of
Negotiability of MB2 Canals 1913
Case Report/Clinical Techniques
this prospective clinical study was to assess the frequency in which the
Reciproc R25 instrument (VDW) is able to scout and reach the working
length (WL) in MB2 canals from maxillary molars. Clinical usage
rationale was based on an assessment of preoperative radiographs
according to the manufacturer’s recommendations (8). Conventional
negotiation using small stainless steel hand files was used as the refer-
ence technique for comparison. The null hypothesis tested was that
there is no difference between the Reciproc R25 and hand file instru-
ments in reaching the apex of MB2 canals from maxillary molars.
Materials and Methods
Ethical Issues and Sample Size Estimation
Approval for the project was obtained from the University
Committee for Research on Human Subjects (2-2010-0051), and
informed consent was acquired from all participants. After approaching
potentially appropriate patients, the practitioners carefully explained
the purpose of the study, and the former were formally invited to partic-
ipate. The clinical procedures were then explained along with the risks
and benefits related to the treatment. Patients’ doubts were clarified if
raised, and written informed consent was obtained.
Power analyses indicated 156 teeth (MB2 canal) per treatment
approach for comparisons were necessary to optimize results and
cost. Accordingly, in total, 341 maxillary molar teeth (270 first molars
and 71 second molars) were included in this study. Two experienced
operators, specialists in endodontics with more than 15 years of prac-
tice, performed the clinical portion of this study. All 341 maxillary
molars were consecutively and independently selected from their
private practice from January 2010 to December 2014, which charac-
terize the multicenter profile of the current setup.
Subject Enrollment and Inclusion/Exclusion Criteria
The main inclusion criterion was first or secondary maxillary
molars routinely referred for primary endodontic treatment. The exclu-
sion criteria were as follows:
1. Maxillary molar teeth requiring endodontic retreatment
2. Accesses through prosthetic crowns
3. Case with incomplete root formation
4. Patients younger than 15 years old
5. Those who did not agree to participate in this study
However, no inclusion restriction was set regarding apical curva-
ture, narrowness degree, or partial radiographic visualization of root
canal space.
Common Treatment Procedures in Both Groups
After local anesthesia was obtained, the tooth was isolated with a
rubber dam. Under illumination and proper magnification using a
dental operating microscope, all previous restorative material and
caries were removed, and a traditional straight-line access was made
with high-speed burs. After initially cleaning the pulp chamber with a
2.5% sodium hypochlorite (NaOCl) solution, ultrasonic tips (CPR
#1–5; Obtura Spartan, Alguion, IL) were used to locate the first mesio-
buccal (MB1) canal. Before the MB1 canal was shaped completely, ul-
trasonic tips were used in the groove between the MB1 canal and the
palatal canals to uncover the MB2 canal’s orifice. Teeth with no MB2
canal were automatically excluded from the study.
Patients were randomly assigned to one of the experimental
groups (conventional hand file preparation or R25 Reciproc prepara-
tion) by a central interactive voice response computer-based system,
which provides a dichotomized position to allocation in one of the treat-
ment groups.
1914 Zuolo et al.
Treatment Groups
Group 1: Conventional Hand File Technique (167 Teeth:
122 First Molars and 45 Second Molars). Negotiation of the
MB2 canals was performed using 21-mm K-files #06, #08, and #10
(C-Pilot, VDW) using the balanced force movement in a crown-down
approach, trying to progress toward the apex using gentle movements
without excessive pressure. No chelating solution was used at this point.
The pulp chamber was flooded with a 2.5% NaOCl solution to keep the
canal lubricated and free from debris during the scouting process.
When resistance was encountered and the files could not progress
inside the canal, the instruments were precurved to reach the full WL.
The entire procedure was done under magnification, and if any defor-
mation of the files was observed, the instruments were discarded.
When initial negotiation was considered successful, preflaring was
done with a Gates Glidden #2 bur, and the WL was determined with an
apex locator (Root Zx min; J. Morita Corp, Tokyo, Japan) established at
the ‘‘0.0’’ reading. At this moment, a distal shift shot radiograph was
taken with a #15 K-file inside in both mesiobuccal canals to confirm
whether the instrument had reached the full WL. If the negotiation of
the MB2 did not allow the file to reach the full WL, the negotiation
was considered unsuccessful.
Group 2: Reciproc System (174 Teeth: 126 First Molars
and 48 Second Molars). Negotiation of the MB2 canal with the
R25 Reciproc instrument was attempted as per manufacturer’s recom-
mendations (8). Operators were trained with the protocol used for 2
months before beginning this study. The R25 Reciproc instrument
has an ISO #25 tip and regressive .08 taper. The R25 instrument was
driven in a reciprocating motor (VDW Silver, VDW) according to the
preset configuration ‘‘Reciproc ALL.’’
After access opening, the R25 instrument was used to preflare the
canal space, advancing until it reached 2/3 of the WL previously esti-
mated through the x-ray. The instrument was moved in a slow and gentle
in-and-out pecking motion with a maximum 3-mm amplitude limit. Af-
ter 3 complete pecking movements, the instrument was removed from
the canal, and its flutes were cleaned off using a sponge box. Similar to
the hand files group, no chelating solution was used at this moment. The
pulp chamber was flooded with a 2.5% NaOCl solution to keep the canal
lubricated and free from debris during the scouting process. After
reaching approximately 2/3 of the canal, the WL was determined using
a # 10 or #15 C-Pilot hand file and apex locator (Root Zx mini apical
locator, J Morita Corp). At this point, the C-Pilot hand file was intro-
duced in the canal passively with a watch winding motion; no filing
was done. On this occasion, if the hand instrument did not reach the
full WL, the R25 instrument was reintroduced in the canal, advancing
more toward the apex. This procedure was repeated until the full WL
could be achieved and confirmed by an apex locator and a #10 C-Pilot
hand file.
After WL determination, a distal shift shot radiograph was taken
with a #15 K-file inside both the MB1 and MB2 canals to confirm nego-
tiation on full length. Canals were then prepared until the Reciproc R25
reached the WL. When resistance (blocking perception) was encoun-
tered and the R25 instrument could not advance toward the apex,
this tooth was recorded as an unsuccessful negotiation. Each R25 in-
strument was used on a single tooth and then discarded (Figs. 1A–G
and 2A–C).
Data Recording and Statistics
Following the criteria used by Wolcott et al (9) in this study, the
MB2 canal has to be negotiated and instrumented separately from the
MB1 canal or within 5 mm of the apex where both mesiobuccal canals
JOE — Volume 41, Number 11, November 2015

Figure 1. Typical case showing the mechanical preparation of the MB2 canal with R25 instrument. (A) Preoperative x-ray. (B) Clinical appearance of the pump
floor where it is possible to see the entrance of the both MB canals (red arrows). (C) The R25 file positioned in the entrance of the MB2 canal. (D) Progress of the
R25 file toward the apex. (E) WL confirmation with a R25 file in the MB2 canal. (F) Clinical appearance of the MB canals after preparation with the R25 instrument.
(G) Final x-ray taken after obturation of the canals.
join. All cases in which the hand files (G1) and R25 instrument (G2)
were able to reach the fully electronically determined WL were classified
as ‘‘reaching full WL’’ (RFWL). All cases in which the hand files (G1) and
R25 instrument (G2) were unable to negotiate the full-length canal were
classified as ‘‘not reaching full WL’’ (NRFWL). The number of root
canals classified as RFWL and NRFWL from both groups were recorded
and tabulated on an Excel data sheet (Microsoft, Redmond, WA). The
frequency distributions (%) of root canals classified as RFWL and
NRFWL were compared with overall-treated canals and for each treat-
ment approach (hand file and R25 instrument) using the Pearson
chi-square test. The a-type error was set at 0.05.
Results
In group 1, the overall results showed that from a total pool of 167
MB2 canals hand files reached the full WL in 57.48% of cases, with 3 frac-
tured instruments recorded. In group 2, the overall results showed that
from a total pool of 174 MB2 canals, the R25 instrument reached the full
WL in 85.63% of cases, also with 3 fractured instruments recorded.
Chi-square tests showed that the observed frequencies of RFWL
and NRFWL canals were significantly different from the expected fre-
quencies to overall-treated canals (P = .000, c2 = 584.89) and for ca-
nal classifications (P = .000, c2 = 381.87 for narrow canals; P = .000,
c2 = 127.12 for medium canals; and P = .000, c2 = 76.19 for large
canals). Additionally, it was observed that the frequency in which the full
WL was reached was not significantly different between the first and sec-
JOE — Volume 41, Number 11, November 2015
Case Report/Clinical Techniques
ond maxillary molars. Moreover, according to Weine et al’s classifica-
tion (10), roots with canals described as type II (ie, separate root canals
leaving the pulp chamber and joining short of the apex) displayed a
similar success rate in reaching the full WL when compared with type
III (ie, 2 separate canals all the way to the apex). The distribution of
type III Weine canals among the groups was balanced (ie, 33% for
G1 and 39% for G2). Table 1 summarizes the overall results.
Discussion
It is common knowledge that canal scouting and negotiating are
very important clinical steps, allowing the clinicians to check the num-
ber of canals and creating unrestricted access to the apex and gauge the
apical diameter (12, 13). This prospective and multicenter clinical
report has shown that the reciprocating-based approach (R25 Reciproc
instrument) was able to scout and reach the full WL in MB2 canals from
maxillary molars in 85.63% of the cases. This percentage is approxi-
mately 32% higher when compared with the conventional hand file
technique (57.48%). Therefore, the tested null hypothesis was rejected.
Common sense would assume that reciprocating preparation, in
which a substantial amount of dentin is removed in a short time using
a single, large-tapered, and fast-cutting instrument, tends to be less effi-
cient in scouting an intricate root canal as the MB2 canal. In other
words, it is counterintuitive that a large-size reciprocating instrument
alone would be able to provide a safe and predictable fully mechanized
canal negotiation. The reason for that is the overall understanding that
Negotiability of MB2 Canals 1915
Case Report/Clinical Techniques

Figure 2. Typical case showing the mechanical preparation of the MB2 canal with hand files. (A) Preoperative x-ray. (B) Transoperative x-ray showing the gutta-
percha cone fit in both mesiobuccal canals with 2 separated apical foramens. (C) Final x-ray taken after obturation of the canals.

endodontic instruments used for the negotiation of narrow and curved
root canals should ideally be of small size and possess specific mechan-
ical properties to allow their progress toward the apex (13–16).
However, the current results showed that the Reciproc R25
instrument was able to reach the full WL without a glide path in a
large number of cases, which is aligned with the in vitro results
from De-Deus et al (17) when working in mandibular molars.
Moreover, Allen et al (18) concluded that the efficacy of the hand
path-finding files with enhanced rigidity (C-Pilot, VDW, and C + Files,
Dentsply Maillefer, Ballaigues, Switzerland) remains questionable,
which is also aligned with current findings. From the present results,
the use of the R25 Reciproc instrument for negotiation and management
of MB2 canals in maxillary molars has shown to be around 32% more
effective than the conventional hand path-finding files approach.
In fact, it is fair to state that the R25 acts mainly as an orifice opener
instrument, and to some measure, its efficacy may be explained using
the interplay of 3 main factors:
1. High flexibility (18)
2. High cutting ability (19)
3. Relative strength at the tip (8)
Plotino et al (20) found that Reciproc instruments have shown sta-
tistically higher cutting efficiency, and the cross-sectional design
appeared to be a more decisive parameter than the type of reciprocating
movement regarding the cutting ability of NiTi instruments. Moreover,
the R25 instrument diameter and taper have made it advantageously
more rigid and thus stronger at the tip than the other available rotary
path-finding instruments. Consequently, in general, the R25 tip does
not easily buckle when confronted with canal narrowness and calcifica-
tion in contrast with conventional path-finding instruments (8). The
overall impression from this study is in accordance with several
in vitro studies using Reciproc instruments (17, 19) because the
R25 instrument usually starts to advance into the coronal third of the
MB2 canal as soon as it is activated; the instrument progress rate
toward the apex seems to depend on the severity of the curvature and
initial calcification as well as on the width of the canal orifice, but,
overall, the advance of the R25 may be slow although it was gradual
most of the time. This efficient inward ability to advance inside the
canal of the reciprocating instruments toward the apex has raised
new perspectives for mechanical preparation, such as those
discussed in this article. The advantages of the reciprocation
kinematics are somehow based on the balanced force concept (17).

TABLE 1. Second Mesiobuccal Canals Considered as Reaching Full Working Length

Technique Teeth Total teeth (n) MB2 considered as FWL, n (%) Total FWL (%)
Hand file First maxillary molar 122 67 (54.9) 59.6
Second maxillary molar 45 29 (64.4)
R25 First maxillary molar 126 107 (84.9) 86.2
Second maxillary molar 48 42 (87.5)
FWL, full working length.

1916 Zuolo et al. JOE — Volume 41, Number 11, November 2015

This technique has shown its clinical relevance in reaching the WL in
severely curved canals prepared with hand files (20). Thus, reciproca-
tion can be considered a mechanically driven balanced force, which
might be related to the efficacy of the instrument in advancing toward
the apex (21), by reducing taper lock because of small instrument cycle
angles and the improved cyclic fatigue resistance (10, 21–25). Of note,
the reciprocating motion per se was able to improve the cyclic fatigue
resistance of several NiTi instruments when compared with rotary
motion (22, 24, 26, 27). Furthermore, the reduced cross-sectional
metal mass plus the use of the superelastic M-Wire alloy provide great
flexibility and cutting ability specifically to the Reciproc instrument,
which also may help understand the current results.
The current report seems to be the first attempt to clinically eval-
uate the root canal preparation with reciprocating motion without the
creation of a conventional glide path. This may be relevant because con-
ventional scouting of MB2 canals with small hand files is a well-known
technically demanding transoperative maneuver. A size #10 K hand file
is usually used in an in-and-out smoothing motion of increasing ampli-
tudes toward the apex. However, in fact, it is a delicate procedure in
complex anatomy canals (7, 8), and, often, iatrogenic errors and
mishaps could occur regardless of the clinician’s skills (8). In the pre-
sent study, out of 338 prepared root canals, 6 fractures (0.56%)
occurred. Because instrument separation remains a source of concern
and leads to increased transoperative stress, this very low fracture rate is
an important input from a technical outlook, which points out that both
engine-driven and hand files are relatively safe procedures to scout and
negotiate MB2 canals. The reciprocating technique separation rate is a
bit higher than the recently reported rate (ie, 0.13% for WaveOne sys-
tem [Dentsply Maillefer] [28] and 0.21% for R25 [19]). To some
extent, this is expected because the current study has managed more
complex root canal anatomy typically found in the MB2 canals.
In summary, it was observed that reciprocating instruments play a
positive role in scouting and negotiating MB2 canals. In other words,
the use of the R25 instrument increased the effectiveness in scouting
and negotiating MB2 canals from maxillary first and second molars by
32%. The results of this study allow clinicians to become more confident
in negotiating root canals using a simpler and still efficient approach
without a technically demanding hand file procedure. One promising
idea for future studies is to assess the reciprocating technique behavior
with less experienced clinicians or undergraduate students.
Acknowledgments
The authors express gratitude to our friends Prof Ghassan
Yared, Prof Rodrigo Sanches Cunha, and Prof Arthur Zuolo for their
precise critical comments and discussion for this study.
The authors deny any conflicts of interest related to this study.
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