Aust Endod J 2021

ORIGINAL RESEARCH

Efficacy of an arrow-shaped ultrasonic tip for the removal of

residual root canal filling materials
Emmanuel J.N.L. Silva, PhD1,2 ; Carolina O. de Lima, MSc1 ; Ana F.A. Barbosa, MSc1;
Cláudio M. Ferreira, MSc1; Bruno M. Crozeta, PhD3; and Ricardo T. Lopes, PhD4
1
Department of Endodontics, School of Dentistry, State University of Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
2
Department of Endodontics, School of Dentistry, Grande Rio University (UNIGRANRIO), Rio de Janeiro, RJ, Brazil
3
Department of Restorative Dentistry, School of Dentistry of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
4
Nuclear Engineering Program, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil

Keywords
root canal retreatment, ultrasonic tip, XP-endo
Finisher R, X-ray microtomography.
Correspondence
Dr Emmanuel João Nogueira Leal Silva, Rua
Herotides de Oliveira, 61/902, Icaraı´, Niterói, RJ,
Brazil. Email: nogueiraemmanuel@hotmail.com
doi: 10.1111/aej.12505
(Accepted for publication 2 March 2021.)
Abstract
This study aimed to evaluate the efficacy of supplementary methods to remove
the remaining root filling material from root canals. Twenty mandibular sin-
gle-rooted teeth were instrumented with Reciproc 25/0.08 and filled with
gutta-percha and AH-Plus sealer, followed by a micro-CT scanning. The
retreatment procedures were performed, the samples were rescanned and
divided into two groups (n = 10) according to the supplementary method: XP-
endo Finisher R and Clearsonic tip. The samples were rescanned and the vol-
ume of remaining root filling material was quantified. Data were analysed sta-
tistically (P < 0.05). The amount of filling material removed after
supplementary methods was higher compared with retreatment procedure
(P < 0.05). XP-endo Finisher R promoted a greater percentage of filling materi-
als reduction in the entire root canal and apical third compared with Clear-
sonic tip (P < 0.05). Supplementary methods were effective in the reduction
of root filling materials. XP-endo Finisher R removed more root filling material
than Clearsonic tip.

cleanliness during root canal retreatment, which was

Introduction
The non-surgical root canal retreatment procedures
depend on the adequate removal of root canal filling
material to avoid the reinfection, promote a satisfactory
cleaning of the root canal system and lead to the success
of the therapy (1,2). Different approaches can be applied
for this objective, such as the use of heat, solvents, hand
instruments, ultrasonic, nickel–titanium rotary or recip-
rocating instruments, adaptive systems or a combination
of those (3–9). However, even with these approaches,
residual gutta-percha and endodontic sealer can remain
on root canals (10–12).
Supplementary methods have been proposed for the
removal of residual root canal filling materials
(8,9,13–15). The XP-endo Finisher R (FKG, La Chaux-de-
Fonds, Switzerland) has been launched in the market
with a new alloy technology that could expand at body
temperature, assuming a snake-shaped form over the
apical millimetres. This design aims to improve
already demonstrated in straight oval-shaped canals
(15,16). The Clearsonic (Helse Ultrasonic, Santa Rosa de
Viterbo, Brazil) is a novel ultrasonic tip considered an
excellent choice for root canal retreatment, according to
the manufacturer. Presenting an arrow-shaped section
and a diameter corresponding to an ISO size 50 file
(0.5 mm; Fig. 1), the instrument has already demon-
strated a favourable result to improve the removal of root
canal filling material in flattened and oval-shaped canals
(13). However, these two instruments have never been
compared before in literature. Assuming that the mecha-
nism of action of these two supplementary methods is
different, it seems appropriate to compare them, to estab-
lish the better protocol in endodontic retreatment.
Therefore, this study attempted to evaluate the efficacy
of supplementary methods (XP-endo Finisher R and
Clearsonic tip) for removing remaining root filling mate-
rial from mandibular single root canals through micro-
computed tomographic (micro-CT) analysis. The null

© 2021 Australian Society of Endodontology Inc 1

Supplementary Methods in Root Canal Retreatment
Figure 1 Scanning electron microscopy of the Clearsonic tip (× 100).
hypothesis tested was that (i) there would be no differ-
ences in the use of supplementary methods for the
removal of root filling material and (ii) there would be no
differences between the XP-endo Finisher R and Clear-
sonic tip in removal of root filling material considered in
the entire root canal and (iii) each separate third.
Material and methods
Sample calculation
The sample size was calculated based on study of De-Deus
et al. (9) The Means: difference between two independent
means (two groups) was selected from the T-tests family
in G*Power 3.1 software (Heinrich Heine-Universität,
Düsseldorf, Germany). Considering α = 0.05 and 95%
power and an effect size = 1.29, it would be necessary a
total sample size of 18 teeth to verify difference between
the tested groups. Ten teeth were assigned to each group.
Specimen selection and grouping
This study was approved by the local ethics committee
(n. 2.633.660). Twenty mandibular single-rooted teeth
with a single canal and similar root length out of a total
of fourth-five were selected for this study. Radiographs
were taken in both mesiodistal and buccolingual direc-
tions to select only oval canals with short diameter of ≥2
at a level 5 mm from the apex, according to the tech-
nique described previously (17). Root canal curvature
was selected based on degree of canal curvature, up to
10° according to Schneider’ classification (18). The
2 © 2021 Australian Society of Endodontology Inc
E. J. N. L. Silva et al.
specimens were extracted no longer than 6 months until
their use and all remaining attached tissue were
removed. The teeth were stored in distilled water until
the time they were to be used.
Root canal treatment
After access cavities preparation, apical patency was
determined by using a size 10 K file (Dentsply Sirona,
Ballaigues, Switzerland) into the root canal until the tip
was visible at the apical foramen. This length was
reduced by 1 mm to establish the working length (WL).
The size 15 K (Dentsply Sirona) file was used for glide
path procedures.
The root canal preparation was performed with the
Reciproc Blue R25 system (VDW, Munich, Germany)
under ‘RECIPROC ALL’ movement on an electric motor
(VDW Silver, VDW) according to the manufacturer’s
instructions. Three ‘in-and-out’ motions were performed,
with a slight apical pressure and an amplitude of 3 mm.
This procedure was repeated for three cycles. The irriga-
tion procedures were performed with 2 mL of 2.5%
NaOCl between cycles (totalising 8 mL of NaOCl in each
tooth). The final irrigation was performed using 2 mL of
2.5% NaOCl, followed by 2 mL of 17% ethylenedi-
aminetetraacetic acid (EDTA), during one minute, and
another 2 mL of 2.5% NaOCl.
Afterwards, root canals were obturated with the single-
cone technique, using AH Plus sealer (Dentsply De Trey,
Konstanz, Germany) and Reciproc Blue R25 gutta-percha
(VDW). Afterwards, the pulp chambers were cleaned and
sealed with composite resin (PermaFlo Purple, Ultradent,
South Jordan, UT, USA). Periapical radiographs in buc-
colingual and mesiodistal directions were performed to
verify the root filling quality. The specimens were stored
in 100% humidity at 37°C for 2 weeks.
Micro-CT acquisition
The teeth were scanned by a micro-CT device (SkyScan
1173, Bruker, Kontich, Belgium) after root canal filling,
after retreatment and after supplementary procedures,
following the parameters: 114 mA and 70 Kv, isotropic
resolution of 17 μm, 360° rotation, rotation step of 0.5,
frame averaging of 3 and 0.5 mm thick aluminium filter.
The images were reconstructed with the NRecon software
(v1.6.1.0, Bruker micro-CT) using 36% beam hardening
correction and ring artefact correction of 4, resulting in
the acquisition of 600–700 axial cross sections per sam-
ple. The volume of root filling material after root canal
filling was measured to verify the similarity of the
included samples. Then, to confirm the intergroup homo-
geneity, the teeth were evaluated based on the volume of
E. J. N. L. Silva et al.
remaining root filling material (mm3) after retreatment
procedures by CTAn (v. 1.6.6.0, Bruker Micro-CT) soft-
ware. Subsequently, the specimens were divided into
two tested groups (n = 10), in accordance with the sup-
plementary method used: XP-endo Finisher R and Clear-
sonic tip.
Retreatment procedures
Retreatment procedures were performed by removing the
previous filling material from root canals with Reciproc
R25 and R40 (VDW) instruments. The instruments were
driven with the VDW Silver motor in a reciprocating
motion ‘RECIPROC ALL’ using in-and-out pecking
motions of 3 mm in amplitude, with a brushing motion
up to the WL. After three pecking motions, the instrument
was removed and cleaned. This procedure was repeated
for three cycles. The irrigation was performed with 10 mL
of 2.5% NaOCl during the retreatment procedures.
Supplementary methods
XP-endo Finisher R
The instrument was placed in a contra-angle hand
piece (VDW Silver), cooled (Endo-Frost; Roeko, Lan-
ðvolume of filling material after R40
volume of filling material after supplementary method x 100Þ
volume of filling material after R40
genau, Germany) and was removed from the plastic
tube in rotation mode by applying a lateral move-
ment. The XP-endo Finisher R was operated with
the VDW Silver motor at 800 rpm and 1 Ncm. Each
canal was irrigated with 1.5 mL of 2.5% NaOCl, and
the instrument was activated for 30 s with slow and
gentle 7–8 mm movements up 1 mm short from the
WL. This procedure was repeated once. A total of
3 mL of 2.5% NaOCl and 1 min of activation were
used.
Ultrasonic Tip
The Clearsonic tip was used with 30% of power in a
piezoelectric ultrasonic device (Enac, Osada, Los Ange-
les, USA). Each canal was irrigated with 1 mL of 2.5%
NaOCl. The instrument was introduced 1 mm short
from the WL and activated for 20 s in the buccolingual
direction using gentle pendulum movements towards
the canal walls. This procedure was repeated twice. A
total of 3 mL of 2.5% NaOCl and 1 min of activation
were used.
© 2021 Australian Society of Endodontology Inc
Supplementary Methods in Root Canal Retreatment
Finally, all root canals were irrigated with 3 mL of
17% EDTA and 4 mL of 2.5% NaOCl using the syringe
and NaviTip 30-G needle (Ultradent, South Jordan, UT,
USA) 1 mm short from the WL.
During supplementary methods, all procedures were
performed at 37 °C with the teeth immersed at water
bath (19). Each ultrasonic tip and XP-endo Finisher R
instrument was used in only two samples. All root canal
preparation and retreatment were performed by a single
operator, specialist in endodontics.
Micro-CT analysis
After retreatment procedure (R40) and supplementary
methods, the teeth were rescanned with the same param-
eters described previously. The images stacks were regis-
tered with their respective preoperative data sets using
affine algorithm of 3D Slicer 4.4.0 software (20), and all
image analysis procedures were performed using the
ImageJ software 1.50d (National Institutes of Health,
Bethesda, MD, USA).
The volume of remaining root filling material (mm3)
was measured before and after the use of supplementary
methods and the percentage of reduction of root filling
materials was calculated using the formula :
The analysis was performed considering the entire root
canal and each separate third. The software CTvol
(v1.6.6.0, Bruker Micro-CT) was used to visualise the
three-dimensional models pre- and post-supplementary
methods, allowing for remaining root filling material to
be identified.
Statistical analysis
The volume of material after root canal filling and the
volume of remaining root filling material (mm3) after
retreatment and after supplementary procedures were
submitted to normality test performed with Shapiro–Wilk
test. Non-normal data were treated with non-parametric
Wilcoxon signed-rank test, while the normally dis-
tributed data were analysed with the parametric inde-
pendent samples t-test. The following parameters were
evaluated: (i) the volume of root filling material after root
canal filling; (ii) the volume of remaining root filling
material after retreatment with R40, comparing the simi-
larity between the groups; and (iii) after the supplemen-
tary methods, comparing the difference between the
3
Supplementary Methods in Root Canal Retreatment E. J. N. L. Silva et al.

groups. It was also evaluated, if the use of supplementary
techniques significantly reduced the amount of filling
material when compared to Reciproc R40 system in each
group. The significance level adopted was 5%. The soft-
ware SPSS 15.0 (SPSS, Inc., Chicago, IL, USA) was used
to all analyses.
Results
All the parameters were normal, except the volume of
root filling after supplementary methods (in the apical
third) and the percentage of reduction of root filling after
supplementary methods (in the coronal and apical third).
The volume of material after root canal filling and the
volume of remaining root filling material (mm3) after
retreatment with Reciproc 40 (baseline) were similar
between the groups (P > 0.05), which indicates similarity
in root filling material between the groups before supple-
mentary techniques.
None of the supplementary methods was capable to
completely remove the root filling material after retreat-
ment procedures. However, the amount of filling mate-
rial removed after supplementary methods (XP-endo
Finisher R and Clearsonic tip) was statistically higher
when compared to Reciproc R40 in each separate third
and when the entire root canal was analysed (P < 0.05).
There was no difference between the supplementary
methods in the middle third as described in Table 1.
However, in the apical third and in the entire root canal,
XP-endo Finisher R promoted a greater percentual reduc-
tion of root filling materials when compared to Clear-
sonic tip (P < 0.05; Fig. 2). Moreover, XP-endo Finisher
R demonstrated greater volume of root filling material
removed when compared to Clearsonic tip in the cervical
third and in the entire root canal (P < 0.05).
Discussion
The root filling material removal is fundamental to
enhance the shaping and cleaning of root canal and pro-
vide a successful retreatment (21). However, no tech-
nique or instrument is capable to remove all root canal
filling materials during root canal retreatment
(14,15,22,23). Hence, new instruments with technology
that expand within the root canal and different ultrasonic
tips, have been proposed (13,16,23).
The amount of filling material in this study was signifi-
cantly reduced after the use of XP-endo Finisher R and
Clearsonic tip. Thus, the first null hypothesis was
rejected. These results are corroborated by previous stud-
ies, which also showed the capacity of XP-endo Finisher
R or ultrasonic activation or mechanical action in remov-
ing root filling material during root canal retreatments
(8,15,16). Regarding the amount of filling material
removed in the cervical third and in the entire root canal,
XP-endo Finisher R demonstrated greater volume of fill-
ing material removed when compared to Clearsonic tip.
These results may be associated with the expanding
action at body temperature of XP-endo Finisher R that
improve the cleanliness during the root canal retreat-
ment, as demonstrated in previous studies evaluating
straight oval-shaped root canals (15,16).
The results of this study demonstrated that XP-endo
Finisher R was associated with a greater percentual

Table 1 Mean, standard deviation and confidence intervals of the data obtained in the experimental groups

Clearsonic XP-endo Finisher R

Mean  SD Mean  SD
[confidence intervals] [confidence intervals]

Cervical Entire root Cervical Entire root

Apical third Middle third third canal Apical third Middle third third canal

Volume of root filling 3.1  0.9 4.4  1.1 6.3  1.5 13.8  3.3 3.4  0.6 4.5  1.0 6.4  1.4 14.3  2.9
(baseline) (mm3) [2.5–3.7] [3.7–5.2] [0.9–7.9] [11.7–16.0] [3.0–3.8] [3.8–5.2] [5.5–7.4] [12.5–16.2]
Volume of root filling 0.8  0.7 0.9  1.2 1.4  1.0 3.1  2.2 0.9  0.8 1.4  1.2 0.7  0.5 3.0  2.0
after R40 (mm3) [0.3–1.2] [0.1–1.7] [0.7–2.1] [1.6–4.6] [0.4–1.4] [0.6–2.1] [0.3–1.0] [1.6–4.3]
Volume of root filling 0.5  0.4a 0.5  0.6a 1.0  0.8a 2.0  1.5a 0.3  0.4a 0.3  0.3a 0.3  0.2b 0.8  0.6b
after supplementary [0.2–0.8] [0.1–0.9] [0.4–1.5] [1.1–3.0] [0.0 - 0.6] [0.1–0.5] [0.1–0.4] [0.4–1.2]
methods (mm3)
% of reduction of root 42.8  25.8b 49.8  31.3a 44.9  27.6 41.5  19.9 69.8  29.0 60.7  34.9 52.6  26.7 61.5  25.7b
a a a a a
filling after [26.0–59.7] [29.3–70.2] [44.8–78.3]
supplementary [26.9–62.9] [28.5–54.5] [ 50.8–88.7] [37.9–83.5] [35.2–70.1]
methods

Different lower-case letters indicate significant statistical differences between groups, in the same third or in the entire canal (P < 0.05).
Bold represents statistical difference in the volume of filling material after the use of supplementary methods, in relation to the use of Reciproc 40
(P < 0.05).

4 © 2021 Australian Society of Endodontology Inc

E. J. N. L. Silva et al.
Figure 2 Representative three-dimensional micro-CT images of XP-endo Finisher group (a) and Clearsonic group (b) after root canal filling (1), retreat-
ment procedures (2) and after the use of supplementary methods (3).
reduction of root filling materials when compared to
Clearsonic tip in the entire root canal. Therefore, the sec-
ond null hypothesis was rejected. The result is in line
with the finding of De-Deus et al. (8), which demon-
strated that XP-endo Finisher R promoted greater root
filling removal when compared to E1-Irrisonic ultrasonic
tip. This result however, contrast with the recent study of
Crozeta et al. (16), which evaluated XP-endo Finisher R
and Flatsonic, and found no statistical difference in
reduction of root filling material between the two differ-
ent supplementary methods.
In the apical third, XP-endo Finisher R was associated
with a greater percentual reduction of root filling materials
(69.76%) when compared to Clearsonic tip (42.84%).
Thus, the third null hypothesis was also rejected. This
might be related by the difference in the tip diameter of
the supplementary instruments. The XP-endo Finisher R
presents a smaller tip diameter (0.30), allowing this sup-
plementary instrument to reach the apical portion more
easily and freely when compared to Clearsonic (0.50 mm
© 2021 Australian Society of Endodontology Inc
Supplementary Methods in Root Canal Retreatment
diameter at the tip). Moreover, XP-endo Finisher R
assumed a snake-shaped form over the apical millimetres,
which could promote greater removal of root filling mate-
rials. It is important to emphasise that the particular anat-
omy of each given root canal is the determining factor as
to if and how the use of Clearsonic tips is recommended.
One good example is cases of greater curvatures and/or
calcification, where it is advised that the instrument
should not be allowed to reach the apical third.
In this study, the XP-endo Finisher R was not used asso-
ciated with a solvent, despite the instructions provided by
the manufacturer, to standardise experimental conditions
between groups, similar to previous studies (15,16). Thus,
the impact that the solvent can cause in the removal of
filling material after the use of XP-endo Finisher R is
unknown. However, previous studies have shown that
the use of solvents is associated with the formation of a
thin layer of softened gutta-percha, which adheres to the
root canal wall and makes the filling material removal and
cleaning the canal walls a greater challenge (2425).
5
Supplementary Methods in Root Canal Retreatment
Regarding pairing of the samples, the teeth were ini-
tially selected based on radiographic images. However, to
ensure the sample matching, a micro-CT scan was per-
formed before retreatment procedures and only after this
evaluation the teeth were divided into groups, allowing
the pairing of samples with similar volume of filling
material and reducing the possible bias between experi-
mental groups.
The analysis of the amount of filling material removed
in each third was performed in this study as the apical third
is considered the most critical region to an adequate disin-
fection and cleaning (26) and the presence of microorgan-
isms in this region could promote the maintenance of
periapical disease (27). Moreover, previous studies showed
that the complete removal of root canal filling is not
achieved, particularly in apical region (28,29). The analysis
by micro-CT has been considered the gold standard tech-
nique for the assessment of the presence of filling material
remnants after retreatment procedures, providing reliable
results (6,14). Based on the results obtained, the perfor-
mance of these types of supplementary methods was extre-
mely effective when the comparison was performed after
the use of R40 instrument, showing their efficacy as an
additional step in retreatment procedures. It is imperative
to highlight that the adequate removal of filling material is
essential to achieve the success of the retreatment proce-
dure. Based on that, the performance of the supplemen-
tary methods in this study and previously studies (8,15,16)
justifies the use of these techniques in the routine of den-
tists, since the results shows their importance as an addi-
tional step. Future studies should evaluate the efficacy of
the association of different supplementary methods aiming
to promote a better removal of filling material. Moreover,
it might be speculated whether these supplementary
methods can provide a microbial reduction, since they pro-
mote a better removal of filling material.
Acknowledgements
The authors deny any conflicts of interest related to this
study. This study was partially funded by FAPERJ and
CAPES.
Disclosure statement
The authors certify that they have no commercial or asso-
ciative interest that represents a conflict of interest in
connection with the manuscript.
Authorship declaration
All authors have contributed significantly, and all
authors are in agreement with the manuscript.
6 © 2021 Australian Society of Endodontology Inc
E. J. N. L. Silva et al.
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