roots international No. 1, 2013

Cover / Editorial / Content / A review of bioceramic technology in endodontics / Using hand files to their full capabilities: A new look at an old yet emerging technology / INITIAL®: The beginning of a new era for endodontic instrumentation? / Endodontic irrigants and irrigant delivery systems / Stropko Irrigator removes debris - making many procedures easier / Produits Dentaires presents PD MTA White / International Events / Submission guidelines / Imprint

Open PDF View E-paper Edit Epaper Edit Epaper ads save

Table of contents

Open Link

Open Link

Open Link

issn 2193-4673

Vol. 9 • Issue 1/2013

roots
international magazine of

1

2013

| CE article
A review of bioceramic
technology in
endodontics

| special
Using hand files to
their full capabilities:
A new look at an old
yet emerging technology

| review
Endodontic irrigants and
irrigant delivery systems

endodontology

[2] => RO0110_01_Titel

[3] => RO0110_01_Titel

editorial _ roots

Dear Reader,
_On 5 March, the Root Canal Anatomy Project (http://rootcanalanatomy.blogspot.com) will have
been online for two years. This project was conceived in the Laboratory of Endodontics of the University
of São Paulo, Brazil. During this time, the blog has registered over 210,000 visitors from 161 countries and
the videos have been watched more than 50,000 times. Considering that root-canal anatomy is a specific
subject in dentistry, we believe that our aim is being achieved.
The original goal of this project was the development and availability of non-commercial educational
resources in the endodontic field for educators, scholars, students, clinicians and the general public. The
main purpose is to demonstrate the complexity of the root-canal system in different groups of teeth and
the limitations of some procedures related to endodontic therapy. In a world where 3-D entertainment
rules, it is unthinkable that dentists, dental students and patients are still being educated using only
2-D models such as radiographs and photographs. The project emphasises the importance of animated
images of the internal anatomy of the teeth in the educational process.

Prof. Marco Versiani, DDS, MS, PhD

People have asked me why the content of this project has not yet been commercialised. Basically, there
are two reasons for this. The first one is that the technology and training of our staff were only possible
because of a government sponsorship. So the government believed in our project and public money was
granted in order to develop our idea. It is thus only fair to make the project content available in the form
of free educational material.
The second reason has been guided by the following: dividing to multiply. Since the blog first went
online, the number of people who appreciate and respect our work has increased exponentially. I have
been invited to travel worldwide to talk about this project and had the unique opportunity to experience
other cultures and met amazing people I would otherwise not have met. Our images have been used on
invitation cards, personal web pages, educational flyers, and even on some covers of roots. Amazing!
It has been a wonderful experience to be a giver and a receiver at the same time. This is the most beautiful
of paradoxes. It is in the very act of giving of ourselves to others that we truly receive all for which we could
ever possibly wish.
While this editorial is not full of references to the newest innovations in endodontics or the answers
to your deep clinical questions, I am sure that you will be able to find such information in the pages of this
marvellous magazine. My purpose here is another one. Considering that this is the first issue of roots in
2013, I would like to wish you a year full of new friendships, happiness, peace, and unforgettable moments
with your family. I hope that you will keep providing the best of your skills in order to fulfil your patients’
needs and use our gift to provide pain release to make this world a better place. Keep giving! Giving is an
act of gratitude. Plant the seeds of generosity through your acts of giving, and you will grow the fruits of
abundance for yourself and those around you. Thank you for supporting us throughout these years.
My best wishes,

Prof. Marco Versiani, DDS, MS, PhD
Major Dental Officer (Brazilian Military Police)
Specialist in endodontics, didactics and bioethics

roots
1
I 03
_ 2013

[4] => RO0110_01_Titel

I content _ roots

page 6

page 20

I editorial

I industry

03

38

Dear Reader
| Prof. Marco Versiani

page 24

Stropko Irrigator removes debris, making many
procedures easier
| Dr John J. Stropko

I CE article
06

A review of bioceramic technology in endodontics
| Drs Ken Koch, Dennis Brave & Allen Ali Nasseh

I special
14

Using hand files to their full capabilities:
A new look at an old yet emerging technology
Twisted Files changed the world of endodontics

Produits Dentaires presents PD MTA White

I meetings
40

| Dr Rich Mounce

20

39

International Events

I about the publisher
41
42

| submission guidelines
| imprint

| Dr Sorin Sirbu

24

INITIAL®: The beginning of a new era for endodontic
instrumentation?
| Dr Matthieu Pérard, Dr Justine Le Clerc, Prof. Pierre Colon &
Prof. Jean-Marie Vulcain

I review
30

Cover image courtesy of Prof. Marco Versiani

Endodontic irrigants and irrigant delivery systems
3-D micro-CT models of a mandibular molar showing the changes of the

| Dr Gary Glassman

original root-canal anatomy (green) after preparation with a multiple-file rotary system.
Each colour represents preparation by one of five instruments. The last image in
the sequence represents the root canal after shaping (red) superimposed on the
original canal (green), demonstrating that most of the surface area was prepared
using the multiple-file system.

page 30

04 I roots
1_ 2013

page 38

page 40

[5] => RO0110_01_Titel

FDI 2013 Istanbul

Annual World Dental Congress
28 to 31 August 2013 - Istanbul, Turkey

Bridging Continents for Global Oral Health

www.fdi2013istanbul.org
congress@fdi2013istanbul.org

[6] => RO0110_01_Titel

I CE article _ bioceramic technology

A review of bioceramic
technology in endodontics
Authors_ Drs Ken Koch, Dennis Brave & Allen Ali Nasseh, USA

roots

prognosis. The option of “saving the natural dentition” is now back on the table.

By reading this article and then taking a short online quiz, you can gain
ADA CERP CE credits. To take the CE
quiz, visit www.dtstudyclub.com.
The quiz is free for subscribers,
who will be sent an access code. Please write support@
dtstudyclub.com if you don’t receive it. Non subscribers
may take the quiz for a $20 fee.

However, before we investigate specific techniques, we must first ask ourselves is, “What are bioceramics?” Bioceramics are ceramic materials specifically designed for use in medicine and dentistry. They
include alumina and zirconia, bioactive glass, glass
ceramics, coatings and composites, hydroxyapatite
and resorbable calcium phosphates.1, 2

_ce credit

Fig. 1_The particle size of BC Sealer
is so fine (less than two microns),
it can actually be delivered with
a 0.012 capillary tip. (Photos/
Provided by Ken Koch, DMD)

Fig. 1

06 I roots
1_ 2013

_Since bioceramic technology was introduced
to endodontics, the response has been exceptional. As
more and more practitioners have thought through
the process, they have been able to see not only the
clear benefits of this technology in endodontics, but
they are now asking how this technology can be
applied to other aspects of dentistry. The application
of bioceramic technology has not only changed
endodontics both surgically and non surgically, it has
also begun to change the way we treatment plan our
patients. As a result of bioceramic technology, we now
have the ability to save more teeth in a predictable
fashion, while, in addition, improving their long-term

There are numerous bioceramics currently in use
in both dentistry and medicine, although more so in
medicine. Alumina and zirconia are among the bioinert ceramics used for prosthetic devices. Bioactive
glasses and glass ceramics are available for use in
dentistry under various trade names. Additionally,
porous ceramics such as calcium phosphate-based
materials have been used for filling bone defects. Even
some basic calcium silicates such as ProRoot MTA
(DENTSPLY) have been used in dentistry as root repair
materials and for apical retrofills.
Although employed in both medical and dental
applications, it is important to understand the specific advantages of bioceramics in dentistry and why
they have become so popular. Clearly the first answer
is related to physical properties. Bioceramics are
exceedingly biocompatible, non–toxic, do not shrink,
and are chemically stable within the biological environment. Additionally, and this is very important in
endodontics, bioceramics will not result in a significant inflammatory response if an over fill occurs
during the obturation process or in a root repair. A
further advantage of the material itself is its ability
(during the setting process) to form hydroxyapatite
and ultimately create a bond between dentin and the
filling material. A significant component of improving this adaptation to the canal wall is the hydrophilic
nature of the material. In essence, it is a bonded
restoration. However, to fully appreciate the properties associated with the use of bioceramic technology,
we must understand the hydration reactions involved
in the setting of the material.

[7] => RO0110_01_Titel

CE article _ bioceramic technology

_EndoSequence BC sealer setting reactions
The calcium silicates in the powder hydrate to
produce a calcium silicate hydrate gel and calcium
hydroxide. The calcium hydroxide reacts with the
phosphate ions to precipitate hydroxyapatite and
water. The water continues to react with the calcium silicates to precipitate additional gel-like calcium silicate hydrate. The water supplied through
this reaction is an important factor in controlling
the hydration rate and the setting time as following:
The hydration reactions (A, B) of calcium silicates
can be approximated as follows:
2[3CaO · SiO2] + 6H2O  3CaO · 2SiO2 · 3H2O + 3Ca(OH)2
2[2CaO · SiO2] + 4H2O  3CaO · 2SiO2 · 3H2O + Ca(OH)2

(A)
(B)

The precipitation reaction (C) of calcium phosphate apatite is as follows:
7Ca(OH)2 + 3Ca(H2PO4 )2  Ca10(PO4 )6 (OH)2 + 12H2O

(C)

For clinical purposes (in endodontics), the advantages of a premixed sealer should be obvious. In
addition to a significant saving of time and convenience, one of the major issues associated with the
mixing of any cement, or sealer, is an insufficient and
non-homogenous mix. Such a mix may ultimately
compromise the benefits associated with the material. Keeping this in mind, a new premixed bioceramic
sealer has been designed that hardens only when
exposed to a moist environment, such as that produced by the dentinal tubules.3
But, what is it specifically about bioceramics that
make them so well suited to act as an endodontic
sealer? From our perspective as endodontists, some
of the advantages are: high pH (12.8) during the initial 24 hours of the setting process (which is strongly
anti-bacterial); they are hydrophilic, not hydrophobic; they have enhanced biocompatibility; they do
not shrink or resorb (which is critical for a sealerbased technique); they have excellent sealing ability;
they set quickly (three to four hours); and they are
easy to use (particle size is so small it can be used in a
syringe).
The introduction of a bioceramic sealer (EndoSequence BC Sealer, Brasseler) allows us, for the first
time, to take advantage of all the benefits associated
with bioceramics but to not limit its use to merely
root repairs and apical retrofills. This is only possible
because of recent nanotechnology developments;
the particle size of BC Sealer is so fine (less than two
microns), it can actually be delivered with a 0.012
capillary tip (Fig. 1).

This material has been specifically designed as a
non-toxic calcium silicate cement that is easy to use
as an endodontic sealer. This is a key point. In addition
to its excellent physical properties, the purpose of BC
Sealer is to improve the convenience and delivery
method of an excellent root canal sealer, while simultaneously taking advantage of its bioactive characteristics (it utilizes the water inherent in the dentinal
tubules to drive the hydration reaction of the material, thereby shortening the setting time).
As we know, dentin is composed of approximately
20 per cent (by volume) water, and it is this water that
initiates the setting of the material and ultimately
results in the formation of hydroxyapatite.4 Therefore,
if any residual moisture remains in the canal after
drying, it will not adversely affect the seal established
by the bioceramic cement. This is very important in
obturation and is a major improvement over previous
sealers. Furthermore, its hydrophilicity, small particle
size and chemical bonding to the canal walls also
contribute to its excellent hydraulics. But there is
another aspect to sealer hydraulics. That is the shape
of the prepared canal itself.
Actually, it all begins with the file. To be more
specific, it all begins with the specific preparation
created by the file—a constant taper preparation.
When using the EndoSequence technique, we can
create either a 0.04 constant taper preparation or a
0.06 taper. The real key is the constant taper preparation, because when accomplished it now gives us
the ability to create predictable, reproducible shapes.
A variable taper preparation is not recommended
because its lack of shaping predictability (and its corresponding lack of reproducibility) will lead to a less
than ideal master cone fit. This lack of endodontic
synchronicity is why all variable taper preparations
are associated with the overly expensive and more
time consuming thermoplastic techniques.

Fig. 2a_This image shows the
excellent adaption of the bioceramic
sealer (and gutta-percha) to the true
shape of the prepared canal.

Fig. 2a

roots
1
I 07
_ 2013

[8] => RO0110_01_Titel

I CE article _ bioceramic technology
Knowing in advance what the final shape (constant
taper preparation) will be is a tremendous advantage
in creating superior hydraulics. Then add in the feature
of laser verified paper points and gutta-percha cones,
and we now start to develop a system where everything matches (true endodontic synchronicity).
This concept of having everything match is so important because it allows us, for the first time, to perform rotary endodontics in a truly conservative fashion and to be able to use a hydraulic condensation
technique. Furthermore, when used in conjunction
with the EndoSequence filing system, this becomes a
synchronized hydraulic condensation technique. This

est reported value was in Group IV, which employed
ActiV GP sealer in combination with regular guttapercha cones. The conclusion of this study was that
employing a bioceramic sealer (such as BC Sealer) is
very promising in terms of strengthening the residual
root and increasing the in vitro fracture resistance of
endodontically treated teeth. This is a very significant
finding, especially regarding the long term retention
of an endodontically treated tooth.
In this particular study, the bioceramic sealer performed best when combined with ActiV GP cones. In
fact, bonding will occur between the bioceramic sealer
and the ceramic particles in the ActiV GP cones as
well as to the bioceramic particles present in the new
bioceramic coated cones (BC cones). The technique of
achieving a true bond between the root canal wall and
the master cone (as a result of creating endodontic
synchronicity and advanced material science) is
known as synchronized hydraulic condensation.

_Synchronized hydraulic condensation

Fig. 2b
Fig. 2b_A composite image
demonstrating the true
excellence of the technique.

has tremendous implications for the tooth as evidenced by a recent study published in the Journal of
Endodontics.5 The purpose of this study was to evaluate and compare the fracture resistance of roots obturated with various contemporary-filling systems. The
investigators (Ghoneim, et. al.) instrumented 40 single-canal premolars using 0.06 taper EndoSequence
files. The teeth were then obturated using four different techniques. Group I used a bioceramic sealer iRoot
SP (IRoot SP is BC Sealer in Europe) in combination with
ActiV GP cones (Brasseler) while Group II used the
bioceramic sealer with regular gutta-percha. Group III
utilized ActiV GP sealer plus ActiV GP cones and Group
IV employed ActiV G sealer with conventional guttapercha cones. All four groups were obturated using a
single cone technique. Ten teeth were left unprepared
and these acted as a negative control for the study.
Following preparation and obturation, all the teeth
were embedded in acrylic molds and then subjected to
a fracture resistance test in which a compressive load
(0.5mm/min) was applied until fracture. Subsequently,
all data was statistically analyzed using the analysis of
variance model and the Turkey post hoc test.
Then results generated were quite remarkable. It
was demonstrated that the significantly highest fracture resistance was recorded for both the negative
control and Group I (bioceramic sealer /Activ GP cone)
with no statistical difference between them. The low-

08 I roots
1_ 2013

The technique with this material is quite straightforward. Simply remove the syringe cap from the
EndoSequence BC Sealer syringe. Then attach an Intra
Canal Tip of your choice to the hub of the syringe. The
Intra Canal Tip is flexible and can be bent to facilitate
access to the root canal. Also, because the particle size
has been milled to such a fine size (less than 2 microns),
a capillary tip (such as a 0.012) can be used to place
the sealer.
Following this procedure, insert the tip of the syringe into the canal no deeper than the coronal one
third. Slowly and smoothly dispense a small amount
of EndoSequence BC Sealer into the root canal. Then
remove the disposable tip from the syringe and proceed to coat the master gutta-percha cone with a thin
layer of sealer. After the cone has been lightly coated,
slowly insert it into the canal all the way to the final
working length. The synchronized master gutta-percha cone will carry sufficient material to seal the apex.6
The precise fit of the EndoSequence gutta-percha
master cone (in combination with a constant taper
preparation) creates excellent hydraulics and, for
that reason, it is recommended that the practitioner
use only a small amount of sealer. Furthermore, as
with all obturation techniques, it is important to insert the master cone slowly to its final working
length. Moreover, the EndoSequence System is now
available with bioceramic coated gutta-percha
cones. So in essence, what we can now achieve with
this technique is a chemical bond to the canal wall,
as a result of the hydroxyapatite that is created during the setting reaction of the bioceramic material
and we also have a chemical bond between the

[9] => RO0110_01_Titel

[10] => RO0110_01_Titel

I CE article _ bioceramic technology
_Materials and methods

Fig. 3a

Sixteen recently extracted human molars were
mounted on individual stubs and underwent an initial high spatial resolution CT scan prior to any treatment. Following biomechanical crown-down canal
preparation to an apical matrix of 35/0.04 and ultrasonic irrigation with 6 per cent sodium hypochlorite,
each sample was scanned a second time. Obturation
was completed using a single matched gutta-percha
cone and EndoSequence BC sealer. The coronal 4mm
of the gutta-percha was thermo-softened and compacted vertically. Subsequent to canal obturation, a
third scan was made.

Fig. 3b

Fig. 3c

Fig. 3d

Figs. 3a–5c_Cases treated with
bioceramics. (Clinical X-rays/
Provided by Allen Ali Nasseh,
DDS, MMSc)

10 I roots
1_ 2013

ceramic particles in the sealer and the ceramic particles on the bioceramic coated cone.

Scanning of the specimens was performed (Actis
150/130, Varian Medical Systems) with a 180-degree
rotation around the vertical axis and a single rotation
step of 0.9 degree with a cross-sectional pixel size of
approximately 24µm. All three backscatter projections
were aligned post-processing with sub-voxel accuracy at 92 per cent CI in VG Studio Max 2.1 (Volume
Graphics GmbH) and manipulated to create regions of
interest for each of the scans.

_Results
Think about what we have just accomplished. We
are now doing root canals in a manner that truly is
easier, faster and better. As further evidence of this
technique, we asked Dr Adam Lloyd, the chairman of
the Department of Endodontics at the University of
Tennessee, to share the results of a study recently
conducted at the University of Tennessee.7

Analysis of volume occupied by sealer in relation to
total original canal volumes was found to be extremely
high with a mean of 97 per cent ± 2.8, much higher than
reported previously using studies on canal surface
area occupancy of material, with 75 per cent of samples occupied at the ≥ 95 per cent level (Figs. 2a, 2b).

Fig. 4a

Fig. 4b

Fig. 4c

Fig. 5a

Fig. 5b

Fig. 5c

[11] => RO0110_01_Titel

CE article _ bioceramic technology

While the properties associated with bioceramics
make them very attractive to dentistry, in general,
what would be their specific advantage if used as an
endodontic sealer? From our perspective as endodontists, some of the advantages are: enhanced biocompatibility, possible increased strength of the root
following obturation, high pH (12.8) during the setting process which is strongly anti-bacterial, sealing
ability related to its hydophilicity, and ease of use.8
Furthermore, the bioceramic sealer does not shrink
upon setting (it actually expands 0.002 per cent) and
once it is fully set, the material will not resorb.

Fig. 6a

Fig. 6b

Fig. 6c

Fig. 6d

The cases pictured in Figs. 3a through 5c demonstrate the excellence of this technique.

_Retreatment of bioceramics
Bioceramic sealer cases are definitely retreatable
yet the issue of retreating these cases (and all the
associated misinformation) is not unlike that of glass
ionomer. Historically there has been confusion about
retreating glass ionomer endodontic cases (glass
ionomer sealer is definitely retreatable when used as
a sealer) and, similarly, there has been confusion
concerning the retreatability of bioceramics.8 The key
is using bioceramics as a sealer, not as a complete
filler. This is why endodontic synchronicity is so important and again, why the use of constant tapers
makes so much sense (it minimizes the amount of
endodontic sealer thereby facilitating retreatment).
The technique itself is relatively straightforward.
The key in retreating bioceramic cases is to use an
ultrasonic with a copious amount of water. This is
particularly important at the start of the procedure in
the coronal third of the tooth. Work the ultrasonic
(with lots of water) down the canal to approximately
half its length. At this point, add a solvent to the canal
(chloroform or xylol) and switch over to an EndoSequence file (#30 or 35/0.04 taper) run at an increased rate of speed (1,000RPM). Proceed with this
file, all the way to the working length, using solvent
when indicated. An alternative is to use hand files for
the final 2-3mm and then follow the gutta-percha
removal with a rotary file to ensure synchronicity.
The case pictured in Figs. 6a and 6b demonstrates
the retreatment of BC Sealer.

_Bioceramics as a root repair material
We are all familiar with the success of MTA (mineral trioxide aggregate) as a root repair and apico
retrofilling material. Furthermore, we realize that
because MTA is a modified Portland cement, it has
some limitations in terms of handling characteristics.
It does not come premixed (and therefore must be
mixed by hand), is difficult to use on retrofills, and has
such a large particle size that it cannot be extruded
through a small syringe. Yet it has a number of favorable characteristics including a pH of 12.5, which is
significantly anti-bacterial. However, in lieu of a
Portand cement-based material, we now have available a medical grade bioceramic repair material.

Figs. 6a–6d_A case demonstrating
retreatment of BC Sealer. (Clinical Xrays/Provided by Allen Ali Nasseh,
DDS MMSc)

This new repair material is, in fact, the EndoSequence Root Repair material, which comes either
premixed in a syringe (just like BC Sealer) or as a premixed putty (Fig. 7). This is a tremendous help not just
in terms of assuring a proper mix but also in terms of
ease of use. We now have a root repair material with
an easy and efficient delivery system. This is a key
development and a serious upgrade. This allows many
clinicians, not just specialists, to take advantage of
its properties.
Fig. 7_EndoSequence Root Repair
Material. (Image courtesy of Real
World Endo)
Fig. 8_A section of material ready for
delievery.

Fig. 7

Fig. 8

roots
1
I 11
_ 2013

[12] => RO0110_01_Titel

I CE article _ bioceramic technology

Fig. 9a

Fig. 9b

Figs. 9a–10c_Cases demonstrate
healing and bone fill in less than six
months. (Clinical X-rays/Provided by
Allen Ali Nasseh, DDS MMSc)

Fig. 9c

EndoSequence Root Repair material specifically has
been created as a white premixed cement for both permanent root canal repairs and apico retrofillings. As a
true bioceramic cement, the advantages of this new repair material are its high pH (pH >12.5), high resistance
to washout, no-shrinkage during setting, excellent biocompatibility, and superb physical properties. In fact, it
has a compressive strength of 50–70MPa, which is similar to that of current root canal repair materials, ProRoot
MTA (DENTSPLY) and BioAggregate (Diadent). However,
a significant upgrade with this material is its particle
size, which allows the premixed material to be extruded
through a syringe rather than inconsistent mixing by
hand and then placement with a hand instrument.
The Clinicians Report (November 2011) published
findings on EndoSequence Root Repair Material. Some
of its noted advantages as a root repair material were:
_easier to use and place than previous similar products,
_good dispenser (tip/syringe) for easy dispensing,
_radiopaque,
_mulitple uses for a variety of clinical conditions,
_no mixing required.
Furthermore, their final conclusion was that 95
per cent of 19 CR Evaluators stated that they would
incorporate EndoSequence Root Repair Material into
their practice. Ninety-five percent rated it excellent or
good and worthy of trial by colleagues.
Another significant piece of research was published
in the Journal of Endodontics, where a research team
investigated the antibacterial activity of EndoSequence
Root Repair material against Enterococcus faecalis. The
aim of this study was to determine whether EndoSequence Root Repair material either in its putty form

Fig. 10a

Fig. 10b

12 I roots
1_ 2013

Fig. 9d

or as a syringeable paste possessed antibacterial properties against a collection of Enterococcus faecalis strains.
As a standard, they compared the ESRRM to MTA. Their
conclusion was, ESRRM, both putty and syringeable
forms and white ProRoot MTA demonstrated similar antibacterial efficacy against clinical strains ofE. faecalis.9
This research again validated earlier studies that
found ESRRM (Putty) and ESSRM (Paste) displayed similar in vitro biocompatiblity to MTA. Additionally, other
studies found that the ESRRM had cell viability similar to
Gray and White MTA in both set and fresh conditions.10
Even more significant research was published
(January 2012) concerning bioceramics in general. In
a comparison of endodontic sealers, it was demonstrated that in various moisture conditions within a
root canal, iRoot SP (EndoSequence BC Sealer) outperformed all the other sealers. The conclusion of
the study was, “Within the experimental conditions
of this in vitrostudy, it can be concluded that the bond
strength of iRoot SP to root dentin was higher than
that of other sealers in all moisture conditions.”11
As mentioned previously, the bioceramic material to
use in surgical cases is the EndoSequence Root Repair
Material (RRM). The ESRRM is available in two different
modes. There is a syringeable RRM (very similar to the
basic BC Sealer in its mode of delivery) and there is also
a RRM putty that is both stronger and malleable. The
consistency of the putty is similar to Cavit G. The RRM
in a syringe is obviously delivered by a syringe tip but the
technique associated with the putty is different.
When using the putty, simply remove a small
amount from the room temperature jar and knead it for

Fig. 10c

[13] => RO0110_01_Titel

CE article _ bioceramic technology

a few seconds with a spatula or in your gloved hands.
Then start to roll it into a hotdog shape. This is very similar to creating similar shapes with desiccated ZOE or
SuperEBA (Bosworth). Once you have created an oblong
shape, you can pick up a section of it with a sterile instrument and use this to deliver it where needed (Fig. 8).
This is an easy technique for apico retro fills, perforation
repairs, and even for resorption defects. After placing
the putty into the apical preparation (or defect) simply
wipe with a moist cotton ball and finish the procedure.
The cases pictured in Figs. 9a to 10c are evidence of
how beautifully this technique works. These cases are so
significant because they clearly demonstrate the extraordinary healing capability of bioceramics, when used
as a repair material. The X-rays display amazing healing
and bone fill in less than six months, in the mandible.

_Pulp capping with bioceramics
One of the other significant benefits of having bioceramics come pre-mixed in a syringe (EndoSequence
Root Repair Material) is the ability for all dentists to
now easily treat young patients in need of pulp caps or
other pulpal therapies (e.g., pulpotomies). Previously,
many specialists considered MTA to be the ideal material for a direct pulp cap because it did not seem to engender a significant inflammatory response in the pulp.
Unfortunately, due to price concerns and the difficulty
of placement, this methodology was not universally
accepted. However, we now have a true bioceramic
material (ESRRM) that not only works well, but is easier to use. It is much easier. Hopefully, this will lead to an
increased use of bioceramics in our pediatric patients
and help these patients save their teeth. All dentists
can benefit from this upgrade in technique.
The technique itself for a direct pulp cap with the
bioceramic root repair material is as follows: Isolate the
tooth under a rubber dam and disinfect the exposure
site with a cotton ball and NaOCl. Apply a small amount
of the RRM from the syringe or, take a small amount
of the RRM putty from the jar, and place this over the
exposure area. Then, cover the bioceramic repair material with a compomer or glass ionomer restoration.
Following the placement of this material, proceed with
the final restoration, including etching if required.
Single visit direct pulp capping is now here.

_Future directions and prosthodontic
applications
The future promises to be even more exciting in the
world of bioceramics. There will be new fast set (8 to 10
minutes) repair materials introduced, as well as a special bioceramic putty for pediatric use (primary teeth).
We have also seen the melding of bioceramic technology into the world of prosthodontic cements, with the

introduction of Ceramir Crown & Bridge (Doxa Dental).
It is easy to predict that we will see more applications of
this technology in different aspects of dental medicine.
In this article, we have introduced a new bioceramic
sealer (EndoSequence BC Sealer) that when combined
with coated cones offers an exciting new obturation
technique (Synchronized Hydraulic Condensation). The
properties associated with the new bioceramic sealer
also allow us to be more conservative in our endodontic shaping which ultimately leads to the preservation
of natural tooth structure. Surgical applications have
also been introduced, and cases shown, which demonstrate the remarkable ability of bioceramics. The future
is bright for bioceramic technology and even more
exciting for dental medicine._
Editorial note: A complete list of references is available from
the publisher.

_about the authors

roots

Dr Ken Koch, received both his DMD and certificate in endodontics
from the University of Pennsylvania School of Dental Medicine. He is
the founder and past director of the New Program in Postdoctoral
Endodontics at the Harvard School of Dental Medicine. Prior to his
dndodontic career, Koch spent 10 years in the Air Force and held,
among various positions, that of chief of prosthodontics at Osan Air
Force Base and chief of prosthodontics at McGuire Air Force Base.
In addition to having maintained a private practice, limited to endodontics, Koch has lectured extensively in both the United States and abroad. He is also the
author of numerous articles on endodontics. Koch is a co-founder of Real World Endo.
Dr Dennis Brave, a diplomate of the American Board of Endodontics and a member of the College of Diplomates, received his
DDS degree from the Baltimore College of Dental Surgery, University of Maryland and his certificate in endodontics from the
University of Pennsylvania. In endodontic practice for over 25
years, he has lectured extensively throughout the world and
holds multiple patents, including the VisiFrame. Formerly an associate clinical professor at the University of Pennsylvania, Brave
currently holds a staff position at The Johns Hopkins Hospital. Along with having authored numerous articles on endodontics, Brave is a co-founder of Real World Endo.
Dr Allen Ali Nasseh, received his MMSc degree and Certificate
in Endodontics from the Harvard School of Dental Medicine in
1997. He received his DDS degree in 1994 from Northwestern
University Dental School. He maintains a private endodontic
practice in Boston (Microsurgicalendo.com) and holds a staff
position at the Harvard’s postdoctoral endodontic program.
Nasseh is the endodontic editor for several dental journals and
periodicals and serves as the Alumni Editor of the “Harvard
Dental Bulletin.” He serves as the Clinical Director of Real World Endo.
The authors may be contacted via thier website, www.RealWorldEndo.com, or via
email at info@realworldendo.com

roots
1
I 13
_ 2013

[14] => RO0110_01_Titel

I special _ instrumentation

Using hand files to their full
capabilities: A new look at an
old yet emerging technology
Author_ Dr Rich Mounce, USA

The endodontist is encouraged to compare their
treatment methods with those described here. The
Mani product line of files is described primarily
because these files are used daily by the author.
Examples of equivalent files are provided alongside of Mani products throughout the article for
comparison.
There are myriad hand file designs, applications,
materials and manufacturing methods. In recent
years, multi axis grinding machines have provided
advancements of true clinical consequence, especially with regard to file flexibility and cutting ability. Given the wide diversity of available designs
and features, it is impossible to discuss the design,
clinical use or precautions required for every hand
file on the market. Neither barbed broaches nor
balanced force technique will be discussed.1
Fig. 1
Fig. 1_Mani D Finders.
(Images provided by Dr Rich Mounce)

_Introduction: Appreciating the unseen
_Despite wide global acceptance of rotary nickel
dimension
titanium (RNT) canal enlargement, hand files remain
central to endodontic practice. It can be argued
persuasively that proper canal negotiation and glide
path creation are key ingredients to successful longterm treatment, along with adequate and appropriate irrigation, canal preparation, coronal seal,
etc. Simply stated, after the preparatory steps of
straight-line access and removal of the cervical
dentinal triangle with orifice openers, if the canal is
not properly negotiated and a glide path prepared
prior to RNT enlargement, cleaning and shaping
procedures cannot be optimal.
This article was written primarily for the general
dentist. It describes stainless steel (and, to a lesser
degree, nickel titanium) hand files, reciprocation
and their clinical application. This article is intended to be a clinical “how to” article, not a literature review, hence a lack of extensive references.

14 I roots
1_ 2013

Hand files allow the clinician to manually “feel”
the unseen dimension in canal anatomy beyond
what radiographs alone can illustrate. Specifically,
by virtue of hand file resistance to apical advancement, the clinician can, by tactile feel, determine the
curvature, calcification, length, the anatomy of the
MC, and if iatrogenic events may have occurred.
Only cone beam technology comes close to providing the tactile information provided by hand files
(Planmeca).
Such tactile information helps determine treatment strategies prior to shaping. Astute RNT use
has, as its foundation, intimate canal knowledge
first by hand files. Forcing RNT files to length without adequate hand file negotiation and a glide path
is the harbinger of file fracture, canal transportation
and inadequate cleaning and shaping.

[15] => RO0110_01_Titel

special _ instrumentation

Fig. 2

_Hand file applications, differentiation
and general use principles

_Principles for maximizing hand file
effectiveness

Fig. 2_Mani K and H Files, and Mani
Reamers.

Hand files differ based on the following (among
other attributes):
1. Material of manufacture (carbon steel, stainless
steel, nickel titanium, among several other less
common materials).
2. Taper (0.02 tapered, variable tapered, greater tapered).
3. Initial cross sectional design before manufacture
(triangular, square, rhomboid, among other initial
shapes).
4. Final cross sectional design.
5. Corrosion resistance.
6. Handle design and material used for the hand file.
7. Tip sizes (of the individual instrument).
8. Progression of tip sizes across the spectrum of a
given set of instruments.
9. How the cutting flutes are produced (twisting,
grinding, among other manufacturing methods).
10. Tip design (active, non cutting, partially cutting).
11. Whether the file is reciprocated, watch-wound
(K files), rotated (K reamers), or used with a pull
stroke (H files).
12. Helix angle, rake angle, cutting angle (if different
from the rake angle) number of flutes (as well as
flute width, depth and number).
13. Possible variability of the cutting angle along the
length of the file.
14. Linear length of the cutting flutes.
15. In addition to the attributes above, hand files are
designed to be stiff versus flexible, aggressive cutting versus less aggressive, finishing files versus bulk
shaping files, among other general classifications.

The use of hand files is based on several universal
assumptions. These assumptions are:
a) Optimal visualization of the access preparation,
ideally through the surgical microscope (Zeiss,
Global Surgical).
b) Optimal radiographic evaluation of the tooth prior
to access preparation including where necessary,
cone beam visualization. For those without CBCT
technology, having two or optimally three different
pre-operative radiographic angles will provide the
best possible visualization of canal anatomy short
of a CBCT scan.
c) Straight line access.
d) Removal of the cervical dentinal triangle prior to
hand file exploration.
e) Copious irrigation at every stage in the procedure,
especially rinsing debris from the access preparation before hand files are inserted.
f) Pre-operative evaluation of the estimated and expected true working length, final taper and master
apical diameter.
g) Curved files negotiate curved canals more effectively than straight ones. The EndoBender pliers
(Axis/Sybron) are an effective instrument to place
the needed curvature onto hand files. Generally,
in canals that have been ledged or transported,
placing an acute, 3- to 5-mm curve onto the apical
portion of the hand file is beneficial. Multiple insertions of curved hand files to bypass blocked and
transported canals (especially ledges) are the rule,
not the exception. Alternatively, if no transportation has occurred (the canal is untouched or easily

Fig. 3_Mani Flexile Files.

Fig. 3

roots
1
I 15
_ 2013

[16] => RO0110_01_Titel

I special _ instrumentation

Fig. 4
Fig. 4_Mani RT Files.

Fig. 5_Mani SEC O K and H Files.

Fig. 5

16 I roots
1_ 2013

negotiable) the clinician can curve the file in their
fingers without an EndoBender.
h) Canals should always be negotiated with hand files
prior to using RNT files. Even if the clinician uses
a RNT glide path creator (PathFile, DENTSPLY Tulsa
or PreShapers, SpecializedEndo), the canal should
be first negotiated by hand to assure patency.
Clinician preference dictates whether a glide path
should be created by hand files or RNT files.
i) In the view of the author, hand files are single use
disposable instruments as they dull rapidly during
clinical function.
j) The use of nickel titanium hand files is a matter of
personal preference. While some clinicians desire
the flexibility and shape memory of nickel titanium hand files, others do not. It should be noted
that nickel titanium hand files are available with
controlled memory, a proprietary thermo mechanical process in which nickel titanium hand files lose
their shape memory yet retain their flexibility.2–4
k) The principles of canal preparation must be observed, irrespective of the methods utilized to
achieve these principles (i.e., hand file canal enlargement and/or RNT enlargement or a combination of these methods). These principles are to:
_leave the canal in its original position (simply enlarge it as described here);
_leave the minor constriction (MC) of the apical
foramen at its original position and size;
_create a tapering funnel with narrowing cross
sectional diameters from orifice to apex;
_create a master apical taper that optimizes irrigation and obturation hydraulics, and yet causes no
iatrogenic events (strip perforation, canal transportation unnecessary dentin removal—and does
not leave the tooth at risk of long term vertical
fracture).

_General classes of hand files
Files primarily designed for canal negotiation
In calcified canals, hand file stiffness is an attribute. Mani D Finder files are representative of this
class and are especially useful for early negotiation of
calcified canals. The D finders have a D shaped cross
section. Some files utilize carbon steel in manufacture and/or possess atypical tip sizes to facilitate
negotiation. Stiffness can be attributed to either the
files design (Mani D Finders) or the use of carbon steel
and/or a combination of carbon steel and a modified
design (Pathfinder CS, Axis/SybronEndo) (Fig. 1).
K files
Generally, K files have a three or four-sided configuration with more spirals than a K reamer. Mani
K Files are four-sided. Overall, K files are the most
“universal” hand files covering the greatest number
of clinical indications.
K files are not as flexible as hand files designed
specifically for flexibility (such as the Mani Flexile
files discussed below) or nickel titanium hand files.
K files are used with a watch-winding hand motion
and can be reciprocated (as described below). The
angle between the cutting flutes and long axis of a
K file is generally in the 25- to 40-degree range.5 Lexicon K Files are an additional example of another
commercially available K file (DENTSPLY Tulsa).
K Reamers
Mani K Reamers are three-sided and contain fewer
spirals than K files. Smaller reamers are generally square

[17] => RO0110_01_Titel

special _ instrumentation

in cross section. Larger reamer sizes are generally triangular. The angle between the cutting flutes and long axis
of a reamer is most often in the 10- to 30-degree range.5
Reamers are used in rotation, unlike K files. Hand
file rotation is associated with less canal transportation than K file watch winding.
The use of K reamers versus K files is a matter of
personal preference. K type instruments of both types
(reamers versus K files) should be manipulated carefully when used counterclockwise due to the risk of
instrument fracture. Lexicon K Reamers are an additional example of a commercially available K reamer
(DENTSPLY Tulsa)—these are triangular in cross section.
H files
H files (Mani H Files as well) have conical spirals
ground into them. They are used on the pull stroke for
gross removal of canal contents in the coronal third
and in retreatment. H files should not be rotated due
to fracture risk inherent in their design. The angle
between the cutting flutes and long axis of an H file is
generally in the 60- to 65-degree range.5

It is not advisable to use H files near the MC. The MC
can be transported easily if H files are used at or beyond
the MC. Clinically, aside from transportation, such an
action lead to significant apical bleeding (Fig. 2).
Hand files of accentuated and variable taper
Mani Flare Files are more tapered than standard
hand files—0.05 taper compared to 0.02 taper. They are
used to prepare tapered canals for doctors who hand
file the entire preparation among other more specialized uses such as verifying taper before cone fit.
Accentuated taper is also available with nickel titanium GT Hand Files. ProFile 0.04 Hand Files are 0.04
tapered and come in a variety of tip sizes, again in
nickel titanium. ProTaper Universal Hand Files feature
the ProTaper variable taper design in shaping and
finishing files in various lengths (all of the above are
manufactured by DENTSPLY Tulsa).
Flexible Files
Mani Flexible Files are triangular in cross section.
Files with a triangular cross section are more flexible

C
AD

I hereby agree to receive a free trail subscription of
(4 issues per year).
I would like to subscribe to
for € 44 including shipping and VAT
for German customers, € 46 including shipping and VAT for customers outside of Germany, unless a written cancellation is sent within 14 days of the receipt of the trial subscription. The subscription will be renewed automatically every year until a written
cancellation is sent to OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig, Germany, six
weeks prior to the renewal date.

Reply via Fax +49 341 48474-290 to OEMUS MEDIA AG or per E-mail to
grasse@oemus-media.de
Last Name, First Name

Company

Street

ZIP/City/Country

DHJ 1/10

roots 1/13

E-mail

Signature

Notice of revocation: I am able to revoke the subscription within 14 days after my order by
sending a written cancellation to OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig, Germany.
Signature

OEMUS MEDIA AG Holbeinstraße 29, 04229 Leipzig, Germany
Tel.: +49 341 48474-0, Fax: +49 341 48474-290, E-Mail: grasse@oemus-media.de

[18] => RO0110_01_Titel

I special _ instrumentation
than those with square cross sections. Flexible stainless steel hand files are generally used in easily negotiated canals. Clinician preference dictates whether
to use flexible stainless steel files relative to nickel
titanium hand instruments (Fig. 3).

article, the terms TWL and MC are synonymous.
The purpose of reciprocation is to save time, reduce
hand fatigue and prepare a space into which RNT
files can subsequently be inserted with minimal
torque stresses (prepare a glide path).

Additional files in this class are Lexicon FlexSSK
Files (DENTSPLY Tulsa). These files are also available in
medium sizes (12, 17, 22, etc.).

Reciprocation is inherently safe. It is difficult to
fracture hand files when this technique is used
appropriately. Fracture or iatrogenic misadventure
generally occurs when the files are inappropriately
placed (well beyond the MC), the wrong type of hand
file is reciprocated (H) and/or the speed is grossly
exaggerated above the recommended levels.

Aggressive cutting files
Mani RT files (possessing a parallelogram crosssection) and a 71-degree cutting angle, making them
more aggressive relative to many of the other files
included here. RT files would be used primarily by
doctors who are hand filing the entire canal in
conjunction with other hand files (Fig. 4).
Nickel titanium files

Fig. 6

GT Hand Files (made of nickel titanium)
are available in various tapers and tip sizes
(DENTSPLY Tulsa). Lexicon FlexNTK Files are
made of nickel titanium and come in various tip sizes while maintaining a constant
taper. As mentioned above, clinician
preference dictates whether a flexible
stainless steel file is more desirable than
a nickel titanium hand file.
Medium sizes, K, H and reamers

Fig. 6_The Synea W&H WA-62.
A reciprocating hand piece
attachment.

Mani provides K Files, H Files and
stainless-steel reamers in medium sizes
(12, 17, 22, 27, etc.). ProFile Series 29
Stainless Steel 0.02 Hand Files have a
constant 29 per cent increase in tip size
in 0.02 taper. Use of medium sizes avoids
the dramatic increase in tip diameter
with increasing tip sizes, especially between a #10
an #15 hand file (a 50 per cent increase in size of the
#15 relative to the #10 hand file).
Safe-ended hand files and reciprocation
Mani SEC O files are available in an H and K file
variety. Both are “safe-ended,” as they do not cut on
their tips. The Mani SEC O K File is ideal for reciprocation. SEC O H files (and H files in general) are not
reciprocated (Figs. 5 & 6).
Reciprocation is a very safe technique, whereby
the clinician can use a reciprocating hand piece attachment to replicate manual hand file watch winding. Clinically, reciprocation is used after the canal
has been negotiated to the TWL and reciprocation
proceeds with the first file that binds at TWL. In this

18 I roots
1_ 2013

Reciprocating hand piece attachments fit onto an E-type coupling and
can be powered at 900rpm, for example
at the 18:1 setting on an electric endodontic motor.
To initiate reciprocation, the file is left in the
canal at the TWL and the reciprocating hand
piece is placed over the file (the file is inserted into
the head of the reciprocating hand piece and is
held there while reciprocating). The attachment
reciprocates the file clockwise and counter clockwise—for example, with a 30-degree clockwise and
30-degree counterclockwise movement. These attachments do not rotate the file a full 360 degrees—
in contrast to how RNT files are powered. Different
reciprocating hand pieces may have variations on
the degree of clockwise or counterclockwise rotation and possibly include a vertical amplitude.
The Synea W&H-62A is an example of a reciprocating hand piece (MounceEndo) attachment
with a 30-degree clockwise and 30-degree counterclockwise motion. Reciprocation is the technique and file motion utilized in the Wave One
canal preparation system (DENTSPLY Tulsa).
Clinically, using the SEC O K File as an example, the
SEC O K File is placed to the TWL, the attachment
placed over the file and reciprocation commences as
described above. The file is reciprocated for 15 to 30
seconds, using a 1- to 3-mm vertical amplitude movement. Clinically, the file will become less tightly bound
as the canal is enlarged.
If, for example, a #08 SEC O K file is the first file that
binds in the canal at TWL this file is reciprocated. Once
the #08 SEC O K File is reciprocated, the canal will now
accept a #10 SEC O K File to TWL. The #10 SEC O K File
is reciprocated. Once reciprocation is complete, the
canal will allow a #15 SEC O K File to reach the TWL.
Once the canal is enlarged to approximately the size
of a #15 or #20 hand file, the canal is ready for RNT
enlargement.

[19] => RO0110_01_Titel

special _ instrumentation

Fig. 7

Fig. 8

Aside from glide path creation, this technique is
especially helpful in early enlargement of calcified
canals, especially the MB2 canal of upper molars.
Reciprocation is also valuable for rubbing out iatrogenic ledges. Once the hand file can negotiate around
the ledge, it is left in place and reciprocated as suggested above.

or 0.04/20 file such as the MounceFile CM (controlled memory) can minimize the risk of subsequent fracture that may otherwise result in moving
directly to a strict crown down approach around
such a curvature. Fracture risk is minimized with the
removal of restrictive dentin along the curvature
through use of the instruments above (Figs. 7 & 8).

It is not advised to place a hand file in a reciprocating handpiece attachment and try to move the file
apically while powering the file. While such a motion
will work some of the time, it can accentuate ledges
and other canal transportations and increase the risk
of file fracture.

Alternatively, instead of using the MounceFile,
the clinician can make an equivalent enlargement
through the curvature using a 0.04/25 Twisted File
(Axis/Sybron) or similarly sized RNT file.

_Integration of the glide path with early
RNT shaping
If the clinician is using RNT shaping methods, the
decision must be made to move either crown down,
step back or possibly use a hybrid of the two strategies. While a comprehensive discussion of such RNT
strategies is beyond the scope of this article, it has
value to mention that judicious initial removal of restrictive dentin at the point of greatest root curvature
(especially in complex cases) is essential to minimize
subsequent iatrogenic events. Caution is advised. RNT
fracture is a risk when the wrong taper and tip size
RNT is inserted into an acute curvature (immediately
after glide path creation) with unnecessary force. In
essence, a strict crown down sequence may not be
indicated.
Anatomically, the aforementioned greatest curvature tends to be in either the middle root third or
at the junction of the middle and apical thirds. Clinically, in complex multiplanar curvatures, after glide
path preparation, regardless of whether the glide
path was made with reciprocation or with a nickel
titanium instrument, using a relatively smaller taper
and tip size RNT file (for example, a 0.02/20, 0.03/20,

Fig. 7_The MounceFile Controlled
Memory nickel titanium files.
Fig. 8_Clinical case treated using the
reciprocating technique described
and the MounceFile in Controlled
Memory.

This article, written for the general dentist, has
described common attributes of hand files, their
clinical use, reciprocation, and integration of glide
path preparation with initial shaping procedures.
Emphasis has been placed on interpreting tactile
feedback and avoidance of iatrogenic events. Your
feedback is welcome._
Editorial note: A complete list of references is available from
the publisher.

_about the author

roots

Dr Rich Mounce is in full
time endodontic practice in
Rapid City, SD. He is the
owner of MounceEndo LLC
and an endodontic supply
company marketing the
MounceFile in Controlled
Memory© and Standard
Nickel Titanium (SNT). MounceEndo is an authorized
dealer of Mani Inc. products and W&H reciprocating
hand piece attachments in USA. He can be reached
at RichardMounce@ MounceEndo.com,
MounceEndo.com, Twitter: @MounceEndo

roots
1
I 19
_ 2013

[20] => RO0110_01_Titel

I special _ instrumentation

Twisted Files changed
the world of endodontics
Case report
Author_ Dr Sorin Sirbu, Romania

Fig. 1_TF 25.12 to 25.04 files.
Fig. 2_The 25.12 file is beginning to
untwist near the tip because of
overworking. This file must be
replaced immediately.

Fig. 3_Clinical examination of tooth
26 revealed a composite filling.
Fig. 4_The initial radiographic
examination showed a massive
composite filling.

Fig. 3

Fig. 1

Fig. 2

_Introduction

systems? Firstly, by its unique machining—which is a
SybronEndo patent.

There are many rotary systems on the dental
market at present. All of these systems are relatively
similar, except for one. This system is called Twisted
Files (TF) and it was introduced to the dental market in
2008. I am glad to have been among the first users of
this system, which has changed the endodontic
world. How does this system differ from other rotary

Fig. 4

20 I roots
1_ 2013

The NiTi wire is brought into a special state
(called R-Phase) that allows the twisting of the file.
This makes TF distinct from all the other systems, for
which the shape of the file is machined by milling,
a mechanical process. This unique procedure lends
particular resistance to TF, as well as an extraordinary

[21] => RO0110_01_Titel

special _ instrumentation

Fig. 5

flexibility. Owing to this manufacturing technique,
a TF untwists before breaking, warning the dentist
in this way. In addition, being made by twisting and
not by polishing/milling, all the microcracks are eliminated, resulting in a more resistant, more robust file.
The manufacturing process is completed by applying
an advanced surface conditioning treatment that
makes the edges active (cutting).
The tip of a TF is inactive, which allows it to follow
the route of the canal easily and to minimise canal
transportation. The working sequence with this system is terribly easy and consequently working time is
reduced.
The files may be recognised and differentiated by
the help of the practical system of codification. There
are two coloured rings: the lower one (closer to the
active part) shows the apical diameter (ISO standard;
for example: red = 25) and the upper one shows the
taper size (Fig. 1). Two working lengths are available:
23 and 27mm.

_The clinical procedure
In this part, I will describe the TF technique. Treatment with TF always begins by creating a glide path
in the canals with #6 to 20 K-files. After opening and
access, treatment inside the canal begins. In the absence of adequate access into the canal, there is the
risk of overworking the file and its subsequent fracture. By opening the canals with K-files, important
information about the anatomy of the root canal is
obtained, such as the existence of curves and the
diameter of the root canal.
Generally, the first TF that is introduced into the
canal is TF 25.08 (the apical diameter is 25mm and it
has a taper of 8%), which in most cases will reach the
working length previously detected by means of an
apex locator. The endodontic engine must be set at
500rpm and the torque at 2Ncm. The file is introduced into the canal in rotation and without pressure
applied. It is sufficient to advance 2 to 4mm when
introducing the file into the canal. If the file does not

Fig. 6

Fig. 5_After removing the composite
filling, a secondary occlusal decay
was observed.
Fig. 6_The opening of the pulp
chamber in tooth 26 and the
identification of the canals.

Fig. 7_The shaped canals ready
for endodontic obturation using
the warm vertical condensation
technique.
Fig. 8_The canals obturated by
means of the warm vertical
condensation technique.

Fig. 7

Fig. 8

roots
1
I 21
_ 2013

[22] => RO0110_01_Titel

I special _ instrumentation

Fig. 9

Fig. 10

Fig. 9_The sealing of the root canals
using RxFlow composite.
Fig. 10_The final composite
restoration.
Fig. 11_The final X-ray showing all
four obturated canals.

Fig. 12_Tooth 37 at the initial clinic
examination.
Fig. 13_The initial radiographic
examination of tooth 37.

Fig. 12

Fig. 11

advance, then a file with a smaller taper (TF 25.06)
must be used instead to achieve working length.
During preparation, there must be sodium hypochlorite in the root canal at all times. The file is cleaned
and examined to detect possible distortion before introduction to the canal and upon withdrawal. If the file
exhibits some distortion, it must be replaced (Fig. 2). If
TF 25.08 reaches working length easily, then a file with
a greater taper can be used (TF 25.10 or 25.12).
After reaching the desired taper, the final apical diameter is prepared. There are many studies in the endodontic literature that have found that apical preparation up to a #25 K-file is insufficient. For this reason,
after reaching the taper the TF 30.06 or 35.06 or both
are used. If greater apical diameters are desired, TF 40.04
or 50.04 can be used. The greater the apical diameter is,
the greater the quantities of irrigation that reach the
apex will be and the cleaner the apex will be. It is generally known that apical preparation by means of rotary
files with large diameters can create many problems
because of the stiffness of the rotary files, such as transportation of the apex and changes to the root-canal
anatomy. With TF, however, this does not occur, owing to
the unique machining process, which ensures that the
files are flexible, even those with large apical diameters.

Fig. 13

22 I roots
1_ 2013

_Case 1
The patient came to our clinic with acute apical
periodontitis around tooth 26. When examined clinically and radiographically, the tooth showed a large
composite filling next to the distal pulp horn (Figs. 3
& 4). The periodontal examination did not find any irregularities; however, the tooth was extremely painful
in vitality tests. Initially, I intended to replace the composite filling. After removing the old composite filling,
I noticed secondary decay that reached up to the pulp
chamber (Fig. 5) and I subsequently decided to pursue
endodontic treatment.
The treatment was performed in one session.
Four canals were identified (MB, MB2, DB and P;
Fig. 6). The main problem was in the MB2 canal,
which had a 90-degree curvature. The treatment was
performed with TF 25.06 in the MB2 canal and with
TF 25.08 in the other canals (Fig. 7). As a final irrigant,
I used SmearClear (SybronEndo). After obturating
the canals with warm vertical condensation using
the Elements Obturation Unit (SybronEndo; Fig. 8),
the canals were sealed with a coloured composite
(RxFlow, Dental Life Sciences; Fig. 9). Finally, the
tooth was restored with a composite filling (Fig. 10)
and the control X-ray was taken (Fig. 11).

[23] => RO0110_01_Titel

special _ instrumentation

Fig. 14

Fig. 15

Fig. 16

_Case 2

_Conclusion

The patient was referred to our clinic by another
doctor who had come across difficulties when
identifying and working in the canals of tooth 37.
The presence of a temporary filling done during
previous treatment was observed during the clinical examination (Fig. 12). An initial X-ray was taken
to identify any possible associated pathology, the
presence of canals, etc. (Fig. 13).

TF permits treatment even in the most difficult
clinical situations and is essential to the dentist.
Using TF, it is possible to widen the apex up to a
#50 K-file without the risk of transporting the
apex. In addition, owing to its unique machining,
TF untwists before separating in the canal, thereby giving the dentist timely warning to replace
the file and significantly decreasing the risk of
accidents while working with the rotary files.
Another major advantage is that this system aids
the maintenance of the root-canal anatomy owing to the remarkable flexibility of the files._

After removing the temporary filling, three root
canals were identified, shaped and cleaned (Fig. 14).
The treatment was performed with TF 25.10 up to
40.04. The MB and ML canals merged, as shown by
the file impression from the MB canal on the guttapercha cone (Fig. 15). The final irrigation was done
with SmearClear. The tooth was obturated with
warm vertical condensation using the Elements
Obturation Unit (Fig. 16), and finally restored with
composite material and a fibreglass post (Fig. 17).

_about the author

Fig. 14_Shaped and cleaned canals.
Fig. 15_The impression left by the
file on the gutta-percha cone attested
to the merging of the MB and ML
canals.
Fig. 16_Final endodontic obturation
by means of the warm vertical
condensation technique.

roots

Dr Sorin Sirbu graduated
from the Carol Davila University of Medicine and Pharmacy
in Bucharest in Romania.
At present, he works in a
private dental practice in
Bucharest.

The control X-ray showed that the root canal and
numerous accessory canals (Fig. 18) had been properly cleaned and obturated due to working with
TF rotary files and negative irrigation with EndoVac
(SybronEndo).

Fig. 17_Tooth 37 restored using
composite material and a fibreglass
post.
Fig. 18_The final X-ray.

Fig. 17

Fig. 18

roots
1
I 23
_ 2013

[24] => RO0110_01_Titel

I special _ instrumentation

INITIAL : The beginning
of a new era for endodontic
instrumentation?
®

Authors_ Dr Matthieu Pérard, Dr Justine Le Clerc, Prof. Pierre Colon & Prof. Jean-Marie Vulcain, France

_Abstract

_Introduction

In the past three decades, numerous endodontic
instruments have been developed to replace traditional steel manual instruments (pulp broaches, Kand H-files), yet sometimes these developments have
not offered the clinical benefits expected. The eighties saw the appearance of more sophisticated instruments, still steel, such as the Unifile (DENTSPLY),
Canal Master U (BRASSELER), Rispi Sonic and Shaper
Sonic (MICRO-MEGA). The nineties and the new century saw an explosion of NiTi instruments; endodontic instrument shapes and methods multiplied to the
point that it was sometimes difficult to keep up. Some
developments were quickly forgotten, others were
widely adopted and remain standards.

During endodontic treatment, after preparation
of the access cavity and first shaping of the canals using a #8, 10 or 15/100 manual file, the practitioner seeks
to widen the canal entrance. This amounts to preparing the coronal third, which in turn allows instruments
to penetrate to the approximate level of the cementoenamel junction. This facilitates root filling.1, 2
Enlarging the canal entrance is performed either
with conventional manual or mechanical instruments
or with instruments designed for this purpose, such as
the ProTaper Universal SX (DENTSPLY Maillefer) or
ENDOFLARE (MICRO-MEGA), or with Gates-Glidden or
other drills.3, 4 Numerous studies have shown the importance of this step prior to root-canal preparation.5–11
INITIAL is a novel instrument for flaring the coronal third of the canal. The instrument is original in its
manufacturing process, its geometry and its motion.
This universal opener is used prior to specific instruments for canal preparation (Fig. 1). It is made of NiTi
and it allows continuous rotation or variable-speed
reciprocating motion, acts like an enlarger to a maximum of 10mm and can be used with a circumferential motion, owing to its blade design.

Fig. 1

Fig. 1_The INITIAL endodontic file.

24 I roots
1_ 2013

The recently launched Initial (NEOLIX), while on
the surface just another new instrument for enlarging canals, deserves close attention because of
its innovative manufacturing process, its shape, its
functionality and its compatibility with the techniques currently in use. It is an instrument that
approaches endodontics differently, perhaps introducing a new era for mechanical endodontic
instrumentation.

_Indications
INITIAL is intended to shape the coronal third of a
canal, on average a length of 5 mm up to a maximum
of 10mm, depending on the tooth’s anatomy. This
preliminary preparation using INITIAL facilitates the
subsequent passage of any sort of canal preparation
instrument down to the apex (Fig. 2). It also allows the
elimination of dentinal irregularities at the level of the
access cavity and facilitates access to the canal orifice.
INITIAL is not intended to reach the apical region but
rather is designed to widen and flare the access.

[25] => RO0110_01_Titel

special _ instrumentation

_Characteristics
INITIAL is a Class IIa medical device according
to Council Directive 93/42/EEC, with the following
characteristics:
_It is an endodontic drill made of NiTi consisting of
a blade mounted on a 15mm mandrel, the active
portion of which is 10mm long.
_The active part is itself divided into two distinct areas.
The first, the apical part, guides the instrument to the
canal lumen and is shaped as a square K-file, 2.5mm
long with an apical diameter of 25/100mm. The second area, the medio-coronal, with a median diameter of 7.5mm, has a double orientation at the cutting
edges of a spiral, one radial (as traditionally found on
endodontic instruments) that works tangentially12
and the other axial, working concomitantly on the
canal walls directly. The combined action of these two
orientations limits the screwing action and allows
the canal entrance to be enlarged safely.
_The taper is 12%, as for other enlarging instrument.
The inactive portion of the blade has an octagonal
cross-section with a diagonal (equivalent to diameter)
reduced to 0.90mm. This increases the flexibility of
the upper part of the instrument, provides better visibility, allows access to the cavity and should a file break
facilitates grasping the piece with endodontic pliers.
_The chuck is 12mm and a standard diameter of
2.35mm allows the instrument to be used with all
endodontic contra-angle handpieces (Fig. 3).
_The combination of the dual orientation of the cutting edge requires either continuous mechanised
rotation or reciprocating motion. This is a characteristic of INITIAL, which can be driven by a rotary engine,
either Marathon Endo-a-class or Marathon Endoe-class (NEOLIX), but any other continuous rotation
motor with electronic control of speed and torque
will suffice (Fig. 4).
In order to exploit the properties of INITIAL optimally, the I-Endo dual (SATELEC ACTEON) motor is
recommended because it is programmable and compatible with the characteristics of INITIAL (Fig. 5).

Fig. 2

For smoothing coronal canal walls, it is possible to
program, if the operator so wishes, a routine of 360degree continuous clockwise rotation followed by
counter-clockwise rotation limited to 180 or 60 degrees, as helped to define extra-oral trials (Fig. 6).

Fig. 2_Radiograph before and after
use of INITIAL (laboratory study):
observe the angles of the canalaccess passages, which increase
significantly after the use of INITIAL.

Recommended speeds vary from 300 to 500rpm
according to the anatomical context. Like any endodontic instrument, INITIAL should have a rotary motion suitable for the clinical situation. It is wise to
commence with a slow speed when entering a canal
channel, which can be increased once the instrument
has freed itself from constraints.13
In cases in which penetration is difficult owing
to obstruction by secondary dentine (calcification) or
in the presence of high curvature, a reciprocating
motion can be established.14 This entails a 360-degree
rotation and a clearance movement of 180 to 60
degrees performed by the I-Endo dual engine; during this disengagement movement, tangential force
diminishes in favour of the direct motion. This is
therefore a period of enlargement without of the
instrument progressing into the canal.
Fig. 3_Dimensional characteristics
of INITIAL.

Fig. 3

roots
1
I 25
_ 2013

[26] => RO0110_01_Titel

I special _ instrumentation
Characteristics

INITIAL
(Neolix)

ENDOFLARE
(Micro-Mega)

ProTaper Universal SX
(DENTSPLY-Maillefer)

Manufacturing process

WEDM

Micro-grinding

Surface treatment

Electro-scouring

Electro-polishing

Aspect

Matt

Shiny

Penetration capacity (mm)

Active zone (mm)

Apical diameter (mm)

25/100

19/100

Taper (%)

Progressive, 3.5 to 8.5

Number of cutting edges

Cross-section active zone

Quadrangular

Triangular

Cross-section inactive zone

Octahedral

Circular

Flutes

Concave

Reinforced by a convex bar

Cutting edges

Tangential and direct

Tangential

Motion type

Continuous rotation or reciprocating

Continuous rotation

Speed (rpm)

300 to 500

300 to 600

300

Maximum torque (N cm)

Mandrel standard diameter (mm)

2.35

2.35, or InGet shaft

2.35

Table 1_Characteristics of enodontic
instruments used to prepare the
coronal part ofthe canal.

_Comparative characteristics of INITIAL
and two currently used enlarging
instruments
The usual reason for using Gates-Glidden, Largo
and other enlarging drills, and NiTi enlarging instruments (DENTSPLY Maillefer; MICRO-MEGA) is to prepare the coronal part of the canal while respecting the
original anatomy.15 Every enlarging instruments has
different characteristics, as shown in Table 1.

_The place of initial in a classical
endodontic protocol

Fig. 4_Marathon Endo-a-class and
Endo-e-class, continuous rotation
endodontic motors.

1. Take an essential preoperative radiograph to assess
the initial root-canal anatomy and the complexity
of the canals and to estimate the working length.
2. After placing the rubber dam, open the pulp chamber of the tooth for extirpation.
3. Debride the pulp chamber with ultrasounds and
irrigate with an antiseptic.
4. Locate the canal entrances with a DG 16 probe
(Hu-Friedy) and evaluate the glide path of the

Table 1

different canals using #8, 10 or 15 K-files. These
preliminary procedures allow the directions of the
canals to be determined and the difficulty of the
preparation to be assessed.
5. Use INITIAL mounted on an endodontic contraangle handpiece (16:1 reduction) on a motor
with programmable speed (initially 300rpm) and
torque limited to a maximum of 3Ncm. Prepare to
a depth of 5mm, with a circumferential motion,
then irrigate thoroughly; the maximum depth
should not go beyond the beginning of the first
curvature. A depth of 10mm should be considered
the maximum (Fig. 7a).
6. Determine the working length electronically or by
preoperative intra-oral radiograph.
7. Continue mechanical preparation, using your preferred instruments. All systems using continuous
rotation or reciprocating motion are compatible
with INITIAL. Do not neglect irrigation.
8. INITIAL can also be used during preparation to
reposition the root-canal entrances (Fig. 7b),
possibly using reciprocating motion (Fig. 8).
9. Continue the preparation to the apical cementodentinal junction using the technology of your
choice.
10. Seal and control.

_Discussion
Why focus on this new instrument? Firstly, because
the machining technology is entirely innovative;
secondly, for its new, variable changing profile; and,
finally, for its clinical functionality, safety, comfort in
use and universality that make this new approach to
endodontics something not to be ignored.

Fig. 4

26 I roots
1_ 2013

[27] => RO0110_01_Titel

special _ instrumentation

Machining
Most endodontic instruments are machined by
micro-grinding.16 This manufacturing method, in use
for many years, is still limited in its ability to produce
complex shapes. Indeed, with the micro-grinding
method, the cutting tool is the grinding wheel, which
has a fixed shape, and it imposes on the object a 3-D
inverse profile. Thus, the geometry of the
object after micro-grinding is predetermined by the shape of the
grinding wheel. This is why almost all endodontic instruments have tangential cutting edges.12 Furthermore,
wear of the micro-grinding
wheel requires constant
adjustment to maintain
the geometrical and diFig. 5
mensional characteristics of the instrument.
Initial is the first instrument to be machined
differently. Its geometry is obtained by wirecut electrical discharge machining (WEDM).17
This technique was developed initially in
1943 in the former USSR by Lazarenko18 and
has been improved since then. It entails melting,
vaporisation and removal of material within a complex dielectric field.19, 20 The energy required for the
machining is generated by electrical discharges passing between two electrodes and creating an electric
arc between the workpiece and the tool (Fig. 9).17 The
advantages of this technology are numerous. Firstly,
the precision of the cut can be measured in microns;21
secondly, machining by localised microfusion then
suppresses any mechanical stress during manufacture, thus avoiding micro-defects and changes in surface properties of the metal by atomic dislocations

Fig. 6

(defects in the alignment of atoms); thirdly, the metal
remains intact, as if it had not been machined; and,
finally, machining parameters remain stable because
the cathode wire that conducts electricity is the only
piece that suffers wear. This technology can provide
an almost total freedom for the production of various
geometric designs because there are no constraints
due to a grinding tool. In addition, compared with
grinding, EDM is more environmentally friendly because it does not require cutting oil, organic solvents or harsh detergents, all of which are
toxic to varying degrees.
WEDM is traditionally used in industrial
sectors such as aerospace, nuclear, medical, general engineering, automotive, and
machine tools to create complex
shapes and articles on a small scale
because the technology is difficult to
implement.22
This process has recently been
modified for the large-scale production
of endodontic instruments; it involves a
dual-wire electrode, consisting of the instrument being manufactured and a mobile EDM wire, yielding very high machining
accuracy, step by step and without physical contact with the workpiece. With this method, the instrument shape is determined by the relative position
in space of the EDM wire and the workpiece. The
spatial positions of the EDM wire and that of the
workpiece can potentially vary independently at any
moment, thus allowing variation in the geometry of
the part, which is not achievable by conventional
machining techniques. Linked to a repetitive mechanism, this technology, innovative in the field of endodontics, differs from the other industrial grinding
processes that are conventionally available.

Fig. 5_I-Endo dual, multifunction
endodontic motor that provides a
choice of continuous rotation or
reciprocating motion.

Fig. 6_Reciprocating-motion
sequences of INITIAL.
Fig. 7a_Illustration of access-cavity
flaring.
Fig. 7b_Illustration of canal-access
repositioning.

Fig. 7a

Fig. 7b

roots
1
I 27
_ 2013

[28] => RO0110_01_Titel

I special _ instrumentation

Fig. 8

Fig. 9

Fig. 8_Intracoronal photographs
of preparation before and after
INITIAL showing access cavities and
canal entrances in teeth
26 and 33 as an example.
Fig. 9_Principle of EDM without
contact between the machining tool
and the workpiece.

This process, which is applicable only to electrically
conductive materials, can change the appearance of
machined metal surfaces.17 In particular, the formation
of irregular layers of metal oxides, 20 to 30µ thick, has
been demonstrated (Fig. 10). This condition requires
that surfaces be chemically treated following EDM to
remove the oxide layers (study of multi-materials and
interfaces undertaken by the Laboratoire des Multimatériaux et Interfaces, a research unit of the National
Centre for Scientific Research and Université Claude
Bernard Lyon 1), while deeper in the material there is
an increase in hardness and increased resistance to
corrosion and wear.17 The surface of the instrument
remains uneven, and it requires a specific chemical
treatment to rid the instrument of these oxide layers
while preserving the quality of cut. This treatment
helps to strengthen the resistance of the instrument’s
surface and limits the risk of crack initiation.17 In order
to reduce fatigue to the base value of the material, it is
necessary to remove the altered layer entirely (Fig. 11).17
In the case of INITIAL, measurement of the torsional
resistance, 3mm from the tip in accordance with standardised ISO tests (ref. 3630-1) with a SOMFY-TAC
(Metil Industrie) torsion meter, gives values compa-

Fig. 10_The layers of metal oxides
after WEDM (Laboratoire des
Multimatériaux et Interfaces).

Fig. 10

28 I roots
1_ 2013

rable to those obtained for the similar NiTi orifice drills
such as the ENDOFLARE (335cN.cm for INITIAL with a
standard deviation of 16.3, compared with 322cN.cm
for the ENDOFLARE with a standard deviation of 38.5).
Values were almost the same when measuring at 45 degrees of flexion, 3mm from the tip (126cN.cm for INITIAL with a standard deviation of 8.3, compared with
134cN.cm for the ENDOFLARE with a standard deviation of 3.2). Comparison with the SX is more difficult,
given the dimensional configuration of the latter, which
is more flexible than other enlarging instruments
(15cN.cm with a standard deviation of 2.5), but it has
significantly less torsional strength (43cN.cm with a
standard deviation of 2.3). The higher the torque, the
more resistant is the instrument, whereas the higher
the bending moment, the less flexible is the instrument.
Variable profile
The shape of INITIAL is original because it develops
a dual geometry. The active blade has four tangential
cutting edges, a pitch of 3.6mm in the apical portion
(0 to 2mm), 4.5mm in the median portion (2 to 6mm)
and 6mm in the coronal portion (6 to 10mm). The blade

[29] => RO0110_01_Titel

special _ instrumentation

also has frontal edges spaced 1.4 to 1.6mm apart,
depending on the portion but only on the 7.5mm
above the apical portion. These characteristics make
INITIAL a very complex instrument with a variable
changing profile along the blade’s working length.
The cutting edges have the ability to work tangentially
like any other flaring instrument, but also frontally.
This last function, in addition to removing dentine
from the canal walls, completes and limits the tangential engagement of the first and allows action
restricted to the coronal portion. This also explains
why INITIAL behaves and acts differently depending
on the working motion.
Furthermore, the inactive blade is octagonal in
cross-section, instead of the usual circular cross-section. This characteristic, in itself not important, could be
an advantage in case of high fracture of the instrument;
in such an event, it would be sufficient to twist the
enlarging instrument counter-clockwise with endodontic pliers to remove the instrument from the canal.
If the dimensional characteristics and indications
for use are at first glance similar to those of other
orifice drills in the market, INITIAL can in no way be
compared with them and the instrument performs
very differently in clinical use.
Clinical functionality and general usefulness
Continuous rotation allows the instrument to develop a dynamic action, tangential to the canal walls,
and to work like a conventional enlarging instrument,
that is, to advance towards the apical region while
widening the canal, owing to the instrument’s 12%
taper. All orifice drills have this property. This is why it
is recommended that periodical checks be performed
for blockage of the cutting edges, frequently observed
on all the enlarging instruments, especially on the first
few millimetres of the instrument, which serve to guide
the penetration into root canals. For this reason, the
use of a motor with torque control is recommended.
Beyond the first 2.5mm, INITIAL will naturally be restrained in its progress by a direct force that is much
more static and therefore opposes the screwing effect.
Using reciprocating motion with the I-Endo dual
motor, particularly 360 degrees clockwise and 180 to
60 degrees counter-clockwise, potentiates the forward force and limits tangential dynamic cutting. This
allows the canal enlargement to be enhanced and/or
monitored without loss of direction.
These two actions, one tangential and dynamic,
the other static and forward, make this instrument an
all-in-one tool. Its use is indicated regardless of the
technique, system or endodontic philosophy preferred
by the clinician.

Fig. 11_Aspect of the surface
after electro-scouring and electropolishing under an optical and
scanning electron microscope.
(Image courtesy of University of
Rennes 1.)

Fig. 11

_Conclusion
INITIAL is the first root-canal instrument to be
machined by WEDM. Its geometry is more complex
than other orifice drills. It has cutting edges that
work tangentially like other endodontic drills and
other edges for surface smoothing, with less torsional
stress, allowing a more anatomical enlargement of
the canal entrance. These simultaneous actions complement each other to limit blockage by debris and
help prevent spontaneous instrument fracture, which
facilitates the subsequent preparation of access to
the apical part of the canal.
It is likely that these advantages of INITIAL will be
incorporated into other root-canal instruments, which
will thus more easily meet the operative, mechanical
and biological requirements of endodontists. In this
manner, initial may introduce a new era for endodontic instrumentation._
Editorial note: A complete list of references is available from
the publisher.

_contact

roots
Prof. Jean-Marie Vulcain
Pôle d’Odontologie
CHU de Rennes
2 place Pasteur
35000 Rennes
France

Prof. Pierre Colon
PU-PH Faculté d’Odontologie
Université de Paris Diderot—Paris 7
APHP
UMR CNRS 5615 Lyon 1
France
Dr Matthieu Perard & Dr Justine Le Clerc
AHU Faculté d’Odontologie
Université de Rennes 1
CHU de Rennes
France

roots
1
I 29
_ 2013

[30] => RO0110_01_Titel

I review _ endodontic irrigation

Endodontic irrigants and
irrigant delivery systems
Author_ Dr Gary Glassman, Canada

_Endodontic treatment is a predictable procedure with high success rates. Success depends on a
number of factors, including appropriate instrumentation, successful irrigation and decontamination of
the root-canal space to the apices and in areas such
as isthmuses. These steps must be followed by complete obturation of the root canals, and placement of
a coronal seal, prior to restorative treatment.
Several irrigants and irrigant delivery systems are
available, all of which behave differently and have
relative advantages and disadvantages. Common
root-canal irrigants include sodium hypochlorite
(NaOCl), chlorhexidine gluconate, alcohol, hydrogen
peroxide and ethylenediaminetetraacetic acid (EDTA).
In selecting an irrigant and technique, consideration
must be given to their efficacy and safety.
With the introduction of modern techniques,
success rates of up to 98% are being achieved.1 The
ultimate goal of endodontic treatment per se is the
prevention or treatment of apical periodontitis such
that there is complete healing and an absence of
infection,2 while the overall long-term goal is the
placement of a definitive, clinically successful restoration and preservation of the tooth. For these to
be achieved, appropriate instrumentation, irrigation,
decontamination and root-canal obturation must
occur, as well as attainment of a coronal seal. There
is evidence that apical periodontitis is a biofilminduced disease.3 A biofilm is an aggregate of microorganisms in which cells adhere to each other and/or
to a surface. These adherent cells are frequently
embedded within a self-produced matrix of extracellular polymeric substance. The presence of microorganisms embedded in a biofilm and growing in the
root-canal system is a key factor for the development
of periapical lesions.4–7 Additionally, the root-canal
system has a complex anatomy that consists of arborisations, isthmuses and cul-de-sacs that harbour
organic tissue and bacterial contaminants (Fig. 1).8
The challenge for successful endodontic treatment
has always been the removal of vital and necrotic rem-

30 I roots
1_ 2013

nants of pulp tissue, debris generated during instrumentation, the dentine smear layer, micro-organisms,
and micro-toxins from the root-canal system.9
Even with the use of rotary instrumentation, the
nickel-titanium instruments currently available only
act on the central body of the root canal, resulting in
a reliance on irrigation to clean beyond what may be
achieved by these instruments.10 In addition, Enterococcus faecalis and Actinomyces prevention or treatment of apical periodontitis such as Actinomyces
israelii—which are both implicated in endodontic
infections and in endodontic failure—penetrate deep
into dentinal tubules, making their removal through
mechanical instrumentation impossible.11, 12 Finally,
E. faecalis commonly expresses multidrug resistance,13–15 complicating treatment.
Therefore, a suitable irrigant and irrigant delivery
system are essential for efficient irrigation and the
success of endodontic treatment.16 Root-canal irrigants must not only be effective for dissolution of the
organic of the dental pulp, but also effectively eliminate bacterial contamination and remove the smear
layer—the organic and inorganic layer that is created
on the wall of the root canal during instrumentation.
The ability to deliver irrigants to the root-canal terminus in a safe manner without causing harm to the patient is as important as the efficacy of those irrigants.
Over the years, many irrigating agents have been
tried in order to achieve tissue dissolution and bacterial decontamination. The desired attributes of a
root-canal irrigant include the ability to dissolve
necrotic and pulpal tissue, bacterial decontamination and a broad antimicrobial spectrum, the ability
to enter deep into the dentinal tubules, biocompatibility and lack of toxicity, the ability to dissolve inorganic material and remove the smear layer, ease of
use, and moderate cost.
As mentioned above, root-canal irrigants currently in use include hydrogen peroxide, NaOCl, EDTA,
alcohol and chlorhexidine gluconate. Chlorhexidine

[31] => RO0110_01_Titel

review _ endodontic irrigation

gluconate offers a wide antimicrobial spectrum, the
main bacteria associated with endodontic infections
(E. faecalis and A. israelii) are sensitive to it, and it is
biocompatible, with no tissue toxicity to the periapical or surrounding tissue.17 Chlorhexidine gluconate,
however, lacks the ability to dissolve necrotic tissue,
which limits its usefulness. Hydrogen peroxide as a
canal irrigant helps to remove debris by the physical
act of irrigation, as well as through effervescing of the
solution. However, while an effective anti-bacterial
irrigant, hydrogen peroxide does not dissolve necrotic
intra-canal tissue and exhibits toxicity to the surrounding tissue. Cases of tissue damage and facial
nerve damage have been reported following use of
hydrogen peroxide as a root-canal irrigant.18 Alcoholbased canal irrigants have antimicrobial activity too,
but do not dissolve necrotic tissue.

such as NaOCl with EDTA are often used as initial and
final rinses to circumvent the shortcomings of a single irrigant.37–39 These irrigants must be brought into
direct contact with the entire canal-wall surfaces
for effective action,20, 37, 40 particularly in the apical
portions of small root canals.9
The combination of NaOCl and EDTA has been used
worldwide for antisepsis of root-canal systems. The
concentration of NaOCl used for root-canal irrigation
ranges from 2.5 to 6%, depending on the country and
local regulations; it has been shown, however, that
tissue hydrolysation is greater at the higher end of
this range, as demonstrated in a study by Hand et al.
comparing 2.5 and 5.25% NaOCl. The higher concentration may also favour superior microbial outcomes.41 NaOCl has a broad antimicrobial spectrum,20
Fig. 1_Root-canal complex.
(Image courtesy of Dr Ronald
Ordinala Zapata, Brazil.)
http://www.facebook.com/
TheInternalAnatomyOfTheHumanTeeth

Fig. 1

The irrigant that satisfies most of the requirements
for a root-canal irrigant is NaOCl.19, 20 It has the unique
ability to dissolve necrotic tissue and the organic
components of the smear layer.19, 21, 22 It also kills sessile endodontic pathogens organised in a biofilm.23, 24
There is no other root-canal irrigant that can meet all
these requirements, even with the use of methods
such as lowering the pH,25–27 increasing the temperature,28–32 or adding surfactants to increase the wetting efficacy of the irrigant.33, 34 However, although
NaOCl appears to be the most desirable single endodontic irrigant, it cannot dissolve inorganic dentine
particles and thus cannot prevent the formation of a
smear layer during instrumentation.35
Calcifications hindering mechanical preparation
are frequently encountered in the root-canal system, further complicating treatment. Demineralising
agents such as EDTA have therefore been recommended as adjuvants in root-canal therapy.20, 36 Thus,
in contemporary endodontic practice, dual irrigants

including but not limited to E. faecalis. NaOCl is superior among irrigating agents that dissolve organic
matter. EDTA is a chelating agent that aids in smear
layer removal and increases dentine permeability,42, 43
which will allow further irrigation with NaOCl to
penetrate deep into the dentinal tubules.44

_General safety precautions
Regardless of which irrigant and irrigation system
is employed, and particularly if an irrigant with tissue
toxicity is used, there are several general precautions
that must be followed. A rubber dam must be used and
a good seal obtained to ensure that no irrigant can spill
from the pulp chamber into the oral cavity. If deep
caries or a fracture is present adjacent to the rubber
dam on the tooth being isolated, a temporary sealing
material must be used prior to performing the procedure to ensure a good rubber dam seal. It is also important to protect the patient’s eyes with safety glasses
and protect clothing from irrigant splatter or spill.

roots
1
I 31
_ 2013

[32] => RO0110_01_Titel

I review _ endodontic irrigation
It is very important to note that while NaOCl has
unique properties that satisfy most requirements for
a root-canal irrigant, it also exhibits tissue toxicity
that can result in damage to the adjacent tissue,
including nerve damage should NaOCl incidents
occur during canal irrigation. Furthermore, Salzgeber
reported in the 1970s that apical extrusion of an
endodontic irrigant routinely occurred in vivo.45 This
highlights the importance of using devices and techniques that minimise or prevent this. NaOCl incidents
are discussed later in this article.

_Irrigant delivery systems
Root-canal irrigation systems can be divided into
two categories: manual agitation techniques and
machine-assisted agitation techniques.9 Manual irrigation includes positive-pressure irrigation, which
is commonly performed with a syringe and a sidevented needle. Machine-assisted irrigation techniques include sonics and ultrasonics, as well as newer
systems such as the EndoVac (SybronEndo), which delivers apical negative-pressure irrigation,46 the plastic
rotary F File (Plastic Endo),47, 48 the Vibringe (Vibringe),49
the Rinsendo (Air Techniques),9 and the EndoActivator
(DENTSPLY Tulsa Dental Specialties).9 Two important
factors that should be considered during the process
of irrigation are whether the irrigation system can deliver the irrigant to the whole extent of the root-canal
system, particularly to the apical third, and whether
the irrigant is capable of debriding areas that could
not be reached with mechanical instrumentation,
such as lateral canals and isthmuses. When evaluating
irrigation of the apical third, the phenomenon of apical vapour lock should be considered.50–52

_Apical vapour lock
Since roots are surrounded by the periodontium,
and unless the root-canal foramen is open, the root
canal behaves like a close-ended channel. This produces an apical vapour lock that resists displacement
during instrumentation and final irrigation, thus preventing the flow of irrigant into the apical region and
adequate debridement of the root-canal system.53, 54
Apical vapour lock also results in gas entrapment at
the apical third.9 During irrigation, NaOCl reacts with
organic tissue in the root-canal system, and the resulting hydrolysis liberates abundant quantities of
ammonia and carbon dioxide.55 This gaseous mixture
is trapped in the apical region and quickly forms a column of gas into which further fluid penetration is impossible. Extension of instruments into this vapour
lock does not reduce or remove the gas bubble,56 just
as it does not enable adequate flow of irrigant.
The phenomenon of apical vapour lock has been
confirmed in studies in which roots were embedded

32 I roots
1_ 2013

in a polyvinylsiloxane impression material to restrict
fluid flow through the apical foramen, simulating
a close-ended channel. The result in these studies
was incomplete debridement of the apical part of the
canal walls with the use of a positive-pressure syringe
delivery technique.57–60 Micro-CT scanning and histological tests conducted by Tay et al. have also confirmed the presence of apical vapour lock.60 In fact,
studies conducted without ensuring a close-ended
channel cannot be regarded as conclusive on the
efficacy of irrigants and the irrigant system.61–63 The
apical vapour lock may also explain why in a number
of studies investigators were unable to demonstrate
a clean apical third in sealed root canals.59, 64–66
In a paper published in 1983, based on research
Chow determined that traditional positive-pressure
irrigation had virtually no effect apical to the orifice
of the irrigation needle in a closed root-canal system.67
Fluid exchange and debris displacement were minimal. Equally important to his primary findings, Chow
set forth an infallible paradigm for endodontic irrigation: “For the solution to be mechanically effective
in removing all the particles, it has to: (a) reach the
apex; (b) create a current (force); and (c) carry the
particles away.”67 The apical vapour lock and consideration for the patient’s safety have always prevented
the thorough cleaning of the apical 3mm. It is critically important to determine which irrigation system
will effectively irrigate the apical third, as well as
isthmuses and lateral canals,16 and in a safe manner
that prevents the extrusion of irrigant.

_Manual agitation techniques
By far the most common and conventional set of irrigation techniques, manual irrigation involves dispensing of an irrigant into a canal through needles/
cannulae of variable gauges, either passively or with
agitation by moving the needle up and down the canal
space without binding it on the canal walls. This allows
good control of needle depth and the volume of irrigant that is flushed through the canal.9, 63 However, the
closer the needle tip is positioned to the apical tissue,
the greater the chance of apical extrusion of the irrigant.67, 68 This must be avoided; were NaOCl to extrude
past the apex, a catastrophic accident could occur.69

_Manual-dynamic irrigation
Manual-dynamic irrigation involves gently moving
a well-fitting gutta-percha master cone up and down
in short 2 to 3mm strokes within an instrumented
canal, thereby producing a hydrodynamic effect and
significant irrigant exchange.70 Recent studies have
shown that this irrigation technique is significantly
more effective than automated-dynamic irrigation
and static irrigation.9, 71, 72

[33] => RO0110_01_Titel

[34] => RO0110_01_Titel

I review _ endodontic irrigation
_Machine-assisted agitation systems
Sonic irrigation
Sonic activation has been shown to be an effective method for disinfecting root canals, operating
at frequencies of 1–6 kHz.73, 74 There are several
sonic irrigation devices on the market. The Vibringe
allows delivery and sonic activation of the irrigating
solution in one step. It employs a two-piece syringe
with a rechargeable battery. The irrigant is sonically
activated, as is the needle that attaches to the syringe. The EndoActivator is a more recently introduced sonically driven canal irrigation system.9, 75 It
consists of a portable handpiece and three types of
disposable polymer tips of different sizes. The EndoActivator has been reported to effectively clean debris from lateral canals, remove the smear layer, and
dislodge clumps of biofilm within the curved canals
of molar teeth.9
Ultrasonics

Fig. 2_EndoVac set-up.

Ultrasonic energy produces higher frequencies
than sonic energy but low amplitudes, oscillating at
frequencies of 25–30kHz.9, 76 Two types of ultrasonic
irrigation are available. The first type is simultaneous
ultrasonic instrumentation and irrigation, and the
second type is referred to as passive ultrasonic irrigation operating without simultaneous irrigation (PUI).
The literature indicates that it is more advantageous
to apply ultrasonics after completion of canal preparation rather than as an alternative to conventional
instrumentation.9, 20, 77 PUI irrigation allows energy to
EndoVac® SET-UP

Macro cannula and
Micro cannula tubing
Master delivery tip
EndoVac adaptor

High volume
suction
Macro cannula
Master delivery tip
(MDT) suction tubing

Micro cannula

Fig. 2

34 I roots
1_ 2013

be transmitted from an oscillating file or smooth wire
to the irrigant in the root canal by means of ultrasonic
waves.9 There is consensus that PUI is more effective
than syringe needle irrigation at removing pulpal tissue remnants and dentine debris.78–80 This may be due
to the much higher velocity and volume of irrigant
flow that are created in the canal during ultrasonic irrigation.9, 81 PUI has been shown to remove the smear
layer; there is a large body of evidence with different
concentrations of NaOCl.9, 80–84 In addition, numerous
investigations have demonstrated that the use of
PUI after hand or rotary instrumentation results in a
significant reduction in the number of bacteria,9, 85–87
or achieves significantly better results than syringe
needle irrigation.9, 84, 88, 89
Studies have demonstrated that effective delivery
of irrigants to the apical third can be enhanced by
using ultrasonic and sonic devices that demonstrate
acoustic micro-streaming and cavitation.79, 81, 90, 91
Acoustic micro-streaming is defined as the movement
of fluids along cell membranes, which occurs as a
result of the ultrasound energy creating mechanical
pressure changes within the tissue. Cavitation is
defined as the formation and collapse of gas and
vapour-filled bubbles or cavities in a fluid.
The Apical Vapor Lock theory, proven in vitro by Tay,
has been clinically demonstrated92 to also include the
middle third by Vera: “The mixture of gases is originally trapped in the apical third, but then it might
grow quickly by the nucleation of the smaller bubbles,
forming a gas column that might not only impede
penetration of the irrigant into the apical third but
also push it coronally after it has been delivered into
the canal.” However, more recently Munoz93 demonstrated that both: passive ultrasonic irrigation (PUI)
and EndoVac are more effective than the conventional endodontic needle in delivering irrigant to WL
of root canals.”
This begs the efficacy question. Two recently published studies examined this issue with both systems
by testing their ability to eliminate microorganisms
during clinical treatment from infected root canal
systems.94, 95 Paiva fund that after a supplementary irrigation procedure using PUI with NaOCl that 23% of
the samples produced positive cultures. Cohenca’s
study examining the clinical efficacy of the EndoVac
fund no microbial growth either after post instrumentation irrigation or at the one92 week obturation
appointment.
When questioning these diverse results one must
remember that microbial hydrolysis via NaOCl is an
equilibrium reaction. Hand demonstrated that a
50% reduction of NaOCl concentration resulted in
a 300% reduction in dissolution activity. Accord-

[35] => RO0110_01_Titel

review _ endodontic irrigation

ingly, one must consider both the delivery of the irrigant to full working length, via PUI or apical negative pressure and the total volume of NaOCl exchanged. The volume of an instrumented root canal
19mm long shaped to a #35 with a 6% instrument
equals .014 cc. Paiva described placement of NaOCl
via a NaviTip (ULTRADENT) at WL – 4mm during instrumentation and discussed using PUI with #15 Kfile at WL – 1mm. Prior to PUI, 2ml of NaOCl was injected into the canal; however, this could not have
filled the apical four millimeters95 due to the apical
vapor lock. According to Munoz, the canal was most
likely immediately filled with ultrasonically activated NaOCl for one minute92, but as just described
– only about .014cc would have been effectively
available for this exchange and activation. In contrast, the Apical Negative Pressure protocol described by Cohenca et al. approximately 2ml of
NaOCl actively passes through the complete WL for
one92 minute.96 The difference in volumetric exchange equals 2/.014 = 14,200% and likely explains
the disinfection differential.

_The plastic rotary F File
Although sonic or ultrasonic instrumentation is
more effective at removing residual canal debris
than rotary endodontic files are,104 and irrigation
solutions are often unable to remove this during
endodontic treatment, many clinicians still do not
incorporate it into their endodontic instrument armamentarium. The common reasons given for not
using sonic or ultrasonic filing are that it can be timeconsuming to set up, an unwillingness to incur the
cost of the equipment, and lack of awareness of the
benefits of this final instrumentation step in endodontic treatment.
It is for these reasons that an endodontic polymerbased rotary finishing file was developed. This new,
single-use, plastic rotary file has a unique file design
with a diamond abrasive embedded into a non-toxic
polymer. The F File will remove dentinal wall debris
and agitate the NaOCl without enlarging the canal
further.

_Pressure-alternation devices
Rinsendo irrigates the canal by using pressure–
suction technology. Its components are a handpiece,
a cannula with a 7mm exit aperture, and a syringe
carrying irrigant. The handpiece is powered by a
dental air compressor and has an irrigation speed of
6.2ml/min. Research has shown that it has promising
results in cleaning the root-canal system, but more
research is required to provide scientific evidence of
its efficacy. Periapical extrusion of irrigant has been
reported with this device.101, 102

_The EndoVac apical negative-pressure
system
The EndoVac apical negative-pressure irrigation
system has three components: the Master Delivery Tip,
MacroCannula and MicroCannula. The Master Delivery Tip simultaneously delivers and evacuates the irrigant (Fig. 2). The MacroCannula is used to suction irrigant from the chamber to the coronal and middle segments of the canal. The MacroCannula or MicroCannula is connected via tubing to the high-speed suction
of a dental unit. The Master Delivery Tip is connected
to a syringe of irrigant and the evacuation hood is connected via tubing to the high-speed suction of a dental unit.56 The plastic MacroCannula has an open end
of ISO size 0.55mm in diameter with a 0.02 taper and
is attached to a handpiece for gross, initial flushing of
the coronal and mid-length parts of the root canal. The
MicroCannula contains 12 microscopic holes and is
capable of evacuating debris to full working length.102
The ISO size 0.32mm diameter stainless-steel MicroCannula has four sets of three laser-cut, laterally
positioned offset holes adjacent to its closed end,
100µ in diameter and spaced 100µ apart. This is attached to a finger piece for irrigation of the apical part
of the canal when it is positioned at working length.
The MicroCannula can be used in canals that are enlarged with endodontic files to ISO size 35.04 or larger.
During irrigation, the Master Delivery Tip delivers
irrigant to the pulp chamber and siphons off the
excess irrigant to prevent overflow. Both the MacroCannula and MicroCannula exert negative pressure
that pulls fresh irrigant from the chamber, down the
canal to the tip of the cannula, into the cannula, and
out through the suction hose. Thus, a constant flow
of fresh irrigant is delivered by negative pressure to
working length. A recent study showed that the volume of irrigant delivered was significantly higher
than the volume delivered by conventional syringe
needle irrigation within the same period,46 and resulted in significantly more debris removal at 1mm
from working length than did needle irrigation.
During conventional root-canal irrigation, clinicians
must be careful when determining how far an irrigation needle is placed into the canal. Recommendations for avoiding NaOCl incidents include not binding the needle in the canal, not placing the needle
close to working length, and using a gentle flow rate
when using positive-pressure irrigation.103 With the
EndoVac, in contrast, irrigant is pulled into the canal
at working length and removed by negative pressure.
Apical negative pressure has been shown to enable irrigants to reach the apical third and help overcome
apical vapour lock.46, 104 In addition, with respect to
isthmus cleaning, although it is not possible to reach
and clean the isthmus area with instruments, it is not
impossible to reach and thoroughly clean these

roots
1
I 35
_ 2013

[36] => RO0110_01_Titel

I review _ endodontic irrigation
lae of NaOCl extrusion have been reported to include life-threatening airway obstructions,109 facial
disfigurement requiring multiple corrective surgical procedures,110 permanent paraesthesia with loss
of facial muscle control,69 and—the least significant consequence—tooth loss.111
Although the exact aetiology of the NaOCl incident is still uncertain, based on the evidence from
actual incidents and the location of the associated
tissue trauma, it would appear that an intravenous
injection may be the cause. The patient shown in
Figure 3 demonstrates a widespread area of tissue
trauma that is in contrast to the characteristics of
NaOCl incident trauma reported by Pashley.108, 112
This extensive trauma, and particularly involving the
pattern of ecchymosis around the eye, could only
have occurred if the NaOCl had been introduced intravenously to a vein close to the root apex through
which extrusion of the irrigant occurred and the
irrigant then found its way into the venous complex.
This would require positive pressure apically that
exceeded venous pressure (10mg of Hg). In one in
vitro study, which used a positive-pressure needle
irrigation technique to mimic clinical conditions
and techniques, the apical pressure generated was
found to be eight times higher than the normal
venous pressure.113
This does not imply that NaOCl can or should be
excluded as an endodontic irrigant; in fact, its use is
critical, as has been discussed in this article. What
this does imply is that it must be delivered safely.

Fig. 3

Fig. 3_Irrigation accident with
widespread trauma.

areas with NaOCl when the method of irrigation is
safe and efficacious. In studies comparing the EndoActivator,105 passive ultrasonic,105 the F File,105 the
manual-dynamic Max-i-Probe (DENTSPLY Rinn),105, 106
the Pressure Ultrasonic111 and the EndoVac,106 only
the EndoVac was capable of cleaning 100% of the
isthmus area.
Apart from being able to avoid air entrapment,
the EndoVac system is also advantageous in its
ability to deliver irrigants safely to working length
without causing their undue extrusion into the
periapex,46, 102 thereby avoiding NaOCl incidents. It
is important to note that it is possible to create
positive pressure in the pulp canal if the Master
Delivery Tip is misused, which would create the risk
of a NaOCl incident. The manufacturer’s instructions
must be followed for correct use of the Master
Delivery Tip.

_Sodium hypochlorite incidents
Although a devastating endodontic NaOCl incident is rare,107 the cytotoxic effects of NaOCl on vital
tissue are well established.108 The associated seque-

36 I roots
1_ 2013

_Safety first
In order to compare the safety of six current
intra-canal irrigation delivery devices, an in vitro
test was conducted using the worst-case scenario
of apical extrusion, with neutral atmospheric pressure and an open apex.102 The study concluded that
the EndoVac did not extrude irrigant after deep intra-canal delivery and suctioning of the irrigant
from the chamber to full working length, whereas
other devices did. The EndoActivator extruded only
a very small volume of irrigant, the clinical significance of which is not known.
Mitchell and Baumgartner tested irrigant (NaOCl)
extrusion from a root canal sealed with a permeable
agarose gel.114 Significantly less extrusion occurred
using the EndoVac system compared with positivepressure needle irrigation. A well-controlled study
by Gondim et al. found that patients experienced
less post-operative pain, measured objectively and
subjectively, when apical negative-pressure irrigation was performed (EndoVac) than with apical positive-pressure irrigation.115

[37] => RO0110_01_Titel

review _ endodontic irrigation

_Efficacy
In vitro and in vivo studies have demonstrated
greater removal of debris from the apical walls and
a statistically cleaner result using apical negativepressure irrigation in closed root-canal systems
with sealed apices. In an in vivo study of 22 teeth by
Siu and Baumgartner, less debris remained at 1mm
from working length using apical negative pressure
compared to use of traditional needle irrigation,
while Shin et al. found in an in vitro study of 69
teeth comparing traditional needle irrigation with
apical negative pressure that these methods both
resulted in clean root canals, but that apical negative pressure resulted in less debris remaining at
1.5 and 3.5 mm from working length.46, 104, 116 When
comparing root-canal debridement using manualdynamic agitation or the EndoVac for final irrigation in a closed system and an open system, it was
found that the presence of a sealed apical foramen adversely affected debridement efficacy when
manual-dynamic agitation was used, but did not
adversely affect results when the EndoVac was used.
Apical negative-pressure irrigation is an effective
method to overcome the fluid-dynamic challenges
inherent in closed root-canal systems.117

_Microbial control
Hockett et al. tested the ability of apical negative pressure to remove a thick biofilm of E. Faecalis,
finding that these specimens rendered negative
cultures obtained within 48 hours, while those irrigated using traditional positive-pressure irrigation
were positive at 48 hours.99
One study found that apical negative-pressure
irrigation resulted in similar bacterial reduction to
use of apical positive-pressure irrigation and a triple
antibiotic in immature teeth.118 In a study comparing the use of apical positive-pressure irrigation
and a triple antibiotic that has been utilised for
pulpal regeneration/revascularisation in teeth with
incompletely formed apices (Trimix = Cipro, Minocin,
Flagyl) versus use of apical negative-pressure irrigation with NaOCl, it was found that the results
were statistically equivalent for mineralised tissue
formation and the repair process.119 Using apical
negative pressure and NaOCl also avoids the risk
of drug resistance, tooth discoloration, and allergic
reactions.120, 121

_Conclusion
Since the dawn of contemporary endodontics,
dentists have been syringing NaOCl into the rootcanal space and then proceeding to place endodontic instruments down the canal in the belief that

I

they were carrying the irrigant to the apical termination. Biological, scanning electron microscopy,
light microscopy, and other studies have proven
this belief to be in error. NaOCl reacts with organic
material in the root canal and quickly forms microbubbles at the apical termination that coalesce
into a single large apical vapour bubble with subsequent instrumentation. Since the apical vapour
lock cannot be displaced via mechanical means, it
prevents further NaOCl flow into the apical area.
The safest method yet discovered to provide fresh
NaOCl safely to the apical terminus to eliminate
the apical vapour lock is to evacuate it via apical negative pressure. This method has also been proven to
be safe because it always draws irrigants to the
source via suction—down the canal and simultaneously away from the apical tissue in abundant
quantities.122 When the proper irrigating agents are
delivered safely to the full extent of the root-canal
terminus, thereby removing 100% of organic tissue
and 100% of the microbial contaminants, success
in endodontic treatment may be taken to levels
never seen before._
Editorial note: A complete list of references is available from
the publisher.
This article has been reprinted in part from G. Glassman,
Safety and Efficacy Considerations in Endodontic Irrigation
(PenWell, January 2011).

_about the author

roots

Dr Gary Glassman graduated from the University of
Toronto Faculty of Dentistry
in 1984 and graduated
from the Endodontology
Program at Temple University in 1987, where he received the Louis I. Grossman Study Club Award for
academic and clinical proficiency in endodontics.
The author of numerous publications, he lectures
globally on endodontics and is on the staff at the
University of Toronto Faculty of Dentistry in the
Graduate Department of Endodontics. He is a fellow
of the Royal College of Dentists of Canada, and
the endodontic editor for the Oral Health journal.
He maintains a private practice, Endodontic
Specialists, in Toronto, Ontario, Canada. He can be
reached through his website, www.rootcanals.ca

roots
1
I 37
_ 2013

[38] => RO0110_01_Titel

I industry _ Stropko Irrigator

Stropko Irrigator removes debris,
making many procedures easier
Author_ Dr John J. Stropko, USA

nating all unintentional splashing or contamination
of the working area. With standard syringe tips, it is
not possible to prevent the dentinal dust from obstructing vision. A good example of vision control
can be observed while troughing in search of hidden
canals, as demonstrated in Figures 2 and 3.
Figure 2 shows how vision is obstructed by the debris created during instrumentation. In Figure 3, note
the vast improvement in vision when the Stropko
Irrigator is used. The dentinal debris is eliminated as it
is created, thus permitting continuous clear vision.

Fig. 1
Fig. 1_The Stropko Irrigator.
(Photographs by Dr. John J. Stropko.)

_The innovative Stropko Irrigator has essential
uses in any discipline of dentistry: to make restorative,
endodontic, periodontal, surgical, and micro-adhesive
dentistry, as well as orthodontic and implant procedures,
easier by constantly maintaining a clean field with uninterrupted vision. The Stropko Irrigator (Fig. 1) allows
numerous advantages over the standard dental tips.
It easily replaces the standard three-way syringe
tip and accepts a variety of Luer-lock tips, enabling more
precise management of irrigation with air and/or water.
The large variety of Luer-lock tips enables direct access
to any area of the mouth, during any procedure,
whether it is the lingual of an anterior, the distal of a
molar, or an apical retro-preparation during surgery.

The outcome of any dental procedure is achieved
easier, faster, with more predictability and less stress.
The advantages of using the Stropko Irrigator are
especially appreciated when using a surgical operating microscope during any dental procedure.
The Stropko Irrigator is available in two lengths:
the 2.5 in. original length (SI-OL) and the 4 in. extra
long (SI-XL). The SI-XL is popular because it allows
the operator or the assistant to remain ergonomically
comfortable and remain clear of the working site.
Using the supplied adapters, the Stropko Irrigator
easily replaces the older three-way syringe tips. No
adapters are needed for the newer quick-connect
three-way syringes.

Using the Stropko Irrigator, cleaning and drying
can be done with more precision and control, elimi-

The Stropko Irrigator is manufactured in the US
in accordance with the strictest of quality-control
measures, and bears the coveted CE marking. It can
be purchased at most dental suppliers in US, or visit
www.stropkoirrigator.com for more information._

Fig. 2

Fig. 3

Fig. 2_Vision is obstructed by
debris created during endodontic
instrumentation.
Fig. 3_When the Stropko Irrigator
is used, debris is eliminated
as it is created.

38 I roots
1_ 2013

[39] => RO0110_01_Titel

industry news _ Produits Dentaires

Produits Dentaires presents
PD MTA White
_PD (Produits Dentaires) Switzerland, developer and manufacturer of MAP Sytem for the precise
placement of repair material in the root canal presented at the IDS 2013 for the first time his PD
MTA White.

Furthermore the very hygienic packaging in two
sachets with 280mg each shows an additional plus
for a safe and successful treatment.
For more information please
visit www.pdsa.ch_

This new endodontic filling material was specially developed to be placed with MAP System
but it could be placed with any other technique as
well. The PD MTA White offers the following advantages:
_Optimized particle size;
_Avoids bacterial migration;
_Excellent marginal sealing capacity;
_Stimulates the formation of a dentine layer (pulp
capping).

_contact

roots

Produits Dentaires SA
Vevey . Switzerland

Produits Dentaires SA
Rue des Bosquets 18
1800 Vevey
Switzerland
info@pdsa.ch

i
AD

I would like to subscribe to
for € 44 including shipping and VAT for German
customers, € 46 including shipping and VAT for customers outside of Germany, unless a
written cancellation is sent within 14 days of the receipt of the trial subscription. The subscription will be renewed automatically every year until a written cancellation is sent to
OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig, Germany, six weeks prior to the
renewal date.

Reply via Fax +49 341 48474-290 to OEMUS MEDIA AG or per E-mail to
grasse@oemus-media.de

Last Name, First Name

Company

Street

ZIP/City/Country

roots 1/13

E-mail

Signature

Notice of revocation: I am able to revoke the subscription within 14 days after my order by
sending a written cancellation to OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig, Germany.
Signature

OEMUS MEDIA AG Holbeinstraße 29, 04229 Leipzig, Germany
Tel.: +49 341 48474-0, Fax: +49 341 48474-290, E-Mail: grasse@oemus-media.de

[40] => RO0110_01_Titel

I meetings _ events

International Events
2013
AAE Annual Session
17–20 April 2013
Hawaii, USA
www.aae.org
35th Asia Pacific Dental Congress
7–12 May 2013
Kuala Lumpur, Malaysia
www.mda.org.my/35th-apdc.htm
CONSEURO Paris 2013
9–11 May 2013
Paris, France
www.paris2013.conseuro.org
IFEA World Endodontic Congress
23–26 May 2013
Tokyo, Japan
www2.convention.co.jp/ifea2013
Sino-Dental
9–12 June 2013
Beijing, China
cnc.sinodent.com.cn/en/index.aspx

20th World Laser Congress
20–22 June 2013
Paris, France
The International Congress of the French Society
of Endodontic (FSE)
20–22 June 2013
Aix en Provence, France
www.endodontie.fr
FDI Annual World Dental Congress
28–31 August 2013
Istanbul, Turkey
www.fdiworldental.org
ESE Biennial Congress
12–14 September 2013
Lisbon, Portugal
www.e-s-e.eu
Canadian Academy of Endodontics
Annual General Meeting
16–22 September 2013
Ottawa, Ontario, Canada
www.caendo.ca
DGZ & DGET joint meeting
10–12 October 2013
Marburg, Germany
www.dget.de
ADA Annual Session
31 October–3 November 2013
New Orleans, USA
www.ada.org
BAET – Successful Endodontics:
Foundations and new Treatment Avenues
8 November 2013
Brussels, Belgium
www.baet.org
Greater New York Dental Meeting
29 November–4 December 2013
New York, USA
www.gnydm.com

40 I roots
1_ 2013

[41] => RO0110_01_Titel

about the publisher _ submission guidelines

submission guidelines:
Please note that all the textual components of your submission
must be combined into one MS Word document. Please do not
submit multiple files for each of these items:
_the complete article;
_all the image (tables, charts, photographs, etc.) captions;
_the complete list of sources consulted; and
_the author or contact information (biographical sketch, mailing
address, e-mail address, etc.).

I

Image requirements
Please number images consecutively throughout the article
by using a new number for each image. If it is imperative that
certain images are grouped together, then use lowercase letters
to designate these in a group (for example, 2a, 2b, 2c).
Please place image references in your article wherever they
are appropriate, whether in the middle or at the end of a sentence.
If you do not directly refer to the image, place the reference
at the end of the sentence to which it relates enclosed within
brackets and before the period.
In addition, please note:

In addition, images must not be embedded into the MS Word
document. All images must be submitted separately, and details
about such submission follow below under image requirements.
Text length
Article lengths can vary greatly—from 1,500 to 5,500 words—
depending on the subject matter. Our approach is that if you
need more or less words to do the topic justice, then please make
the article as long or as short as necessary.
We can run an unusually long article in multiple parts, but this
usually entails a topic for which each part can stand alone because it contains so much information.
In short, we do not want to limit you in terms of article length,
so please use the word count above as a general guideline and if
you have specific questions, please do not hesitate to contact us.
Text formatting
We also ask that you forego any special formatting beyond the
use of italics and boldface. If you would like to emphasise certain
words within the text, please only use italics (do not use underlining or a larger font size). Boldface is reserved for article headers.
Please do not use underlining.
Please use single spacing and make sure that the text is left justified. Please do not centre text on the page. Do not indent paragraphs, rather place a blank line between paragraphs. Please do
not add tab stops.

_We require images in TIF or JPEG format.
_These images must be no smaller than 6 x 6 cm in size at 300 DPI.
_These image files must be no smaller than 80 KB in size (or they
will print the size of a postage stamp!).
Larger image files are always better, and those approximately
the size of 1 MB are best. Thus, do not size large image files down
to meet our requirements but send us the largest files available.
(The larger the starting image is in terms of bytes, the more leeway the designer has for resizing the image in order to fill up more
space should there be room available.)
Also, please remember that images must not be embedded into
the body of the article submitted. Images must be submitted
separately to the textual submission.
You may submit images via e-mail, via our FTP server or post
a CD containing your images directly to us (please contact us
for the mailing address, as this will depend upon the country from
which you will be mailing).
Please also send us a head shot of yourself that is in accordance
with the requirements stated above so that it can be printed with
your article.
Abstracts
An abstract of your article is not required.

Should you require a special layout, please let the word processing
programme you are using help you do this formatting automatically. Similarly, should you need to make a list, or add footnotes
or endnotes, please let the word processing programme do it for
you automatically. There are menus in every programme that will
enable you to do so. The fact is that no matter how carefully done,
errors can creep in when you try to number footnotes yourself.

Author or contact information
The author’s contact information and a head shot of the author
are included at the end of every article. Please note the exact
information you would like to appear in this section and format it according to the requirements stated above. A short
biographical sketch may precede the contact information
if you provide us with the necessary information (60 words
or less).

Any formatting contrary to stated above will require us to remove
such formatting before layout, which is very time-consuming.
Please consider this when formatting your document.

Questions?
Magda Wojtkiewicz (Managing Editor)
m.wojtkiewicz@oemus-media.de

roots
1
I 41
_ 2013

[42] => RO0110_01_Titel

I about the publisher _ imprint

roots
international magazine of

endodontology

Publisher
Torsten R. Oemus
oemus@oemus-media.de

CEO
Ingolf Döbbecke
doebbecke@oemus-media.de

Published by
Oemus Media AG
Holbeinstraße 29
04229 Leipzig, Germany
Tel.: +49 341 48474-0
Fax: +49 341 48474-290
kontakt@oemus-media.de
www.oemus.com

Magda Wojtkiewicz, Managing Editor

Printed by
Members of the Board
Jürgen Isbaner
isbaner@oemus-media.de
Lutz V. Hiller
hiller@oemus-media.de

Managing Editor
Magda Wojtkiewicz
m.wojtkiewicz@oemus-media.de

Executive Producer
Gernot Meyer
meyer@oemus-media.de

Designer
Josephine Ritter
j.ritter@oemus-media.de

Copy Editors
Sabrina Raaff
Hans Motschmann

Silber Druck oHG
Am Waldstrauch 1
34266 Niestetal, Germany

Editorial Board
Fernando Goldberg, Argentina
Markus Haapasalo, Canada
Ken Serota, Canada
Clemens Bargholz, Germany
Michael Baumann, Germany
Benjamin Briseno, Germany
Asgeir Sigurdsson, Iceland
Adam Stabholz, Israel
Heike Steffen, Germany
Gary Cheung, Hong Kong
Unni Endal, Norway
Roman Borczyk, Poland
Bartosz Cerkaski, Poland
Esteban Brau, Spain
José Pumarola, Spain
Kishor Gulabivala, United Kingdom
William P. Saunders, United Kingdom
Fred Barnett, USA
L. Stephan Buchanan, USA
Jo Dovgan, USA
Vladimir Gorokhovsky, USA
James Gutmann, USA
Ben Johnson, USA
Kenneth Koch, USA
Sergio Kuttler, USA
John Nusstein, USA
Ove Peters, USA
Jorge Vera, Mexico

Copyright Regulations
_roots international magazine of endodontology is published by Oemus Media AG and will appear in 2013 with one issue every quarter. The magazine
and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable
to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to
check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited
books and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, represent
the opinion of the afore-mentioned, and do not have to comply with the views of Oemus Media AG. Responsibility for such articles shall be borne by the author.
Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed
for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty
representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany.

42 I roots
1_ 2013

[43] => RO0110_01_Titel

roots

You can also subscribe via
www.oemus.com/abo

would like to subscribe to roots for € 44 including
shipping and VAT for German customers, € 46 including
shipping and VAT for customers outside Germany, unless
a written cancellation is sent within 14 days of the
receipt of the trial subscription. The subscription will
be renewed automatically every year until a written
cancellation is sent to OEMUS MEDIA AG, Holbeinstr. 29,
04229 Leipzig, Germany, six weeks prior to the renewal date.

Last Name, First Name
Company
Street
ZIP/City/Country

Reply via Fax to +49 341 48474-290 to

E-mail

OEMUS MEDIA AG or via E-mail to
grasse@oemus-media.de

Notice of revocation: I am able to revoke the subscription within 14 days after my order by sending a written cancellation to OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig, Germany.

Signature

roots 1/13

Signature

OEMUS MEDIA AG
Holbeinstraße 29, 04229 Leipzig, Germany, Tel.: +49 341 48474-0, Fax: +49 341 48474-290, E-mail: grasse@oemus-media.de

[44] => RO0110_01_Titel

PD MTA White
Load your MAP System

PD MTA White
Optimierte Partikelgröße
Verhindert bakterielle Migration
Exzellente Randabdichtung
Stimuliert die Bildung einer Dentinschicht (Überkappung)
2 Beutel mit je 280 mg

Produits Dentaires SA . Rue des Bosquets 18 . 1800 Vevey . Switzerland . www.pdsa.ch

) [page_count] => 44 [pdf_ping_data] => Array ( [page_count] => 44 [format] => PDF [width] => 595 [height] => 842 [colorspace] => COLORSPACE_UNDEFINED ) [linked_companies] => Array ( [ids] => Array ( ) ) [cover_url] => [cover_three] =>

[cover] => roots international No. 1, 2013

[toc] => Array ( [0] => Array ( [title] => Cover [page] => 01 ) [1] => Array ( [title] => Editorial [page] => 03 ) [2] => Array ( [title] => Content [page] => 04 ) [3] => Array ( [title] => A review of bioceramic technology in endodontics [page] => 06 ) [4] => Array ( [title] => Using hand files to their full capabilities: A new look at an old yet emerging technology [page] => 14 ) [5] => Array ( [title] => INITIAL®: The beginning of a new era for endodontic instrumentation? [page] => 24 ) [6] => Array ( [title] => Endodontic irrigants and irrigant delivery systems [page] => 30 ) [7] => Array ( [title] => Stropko Irrigator removes debris - making many procedures easier [page] => 38 ) [8] => Array ( [title] => Produits Dentaires presents PD MTA White [page] => 39 ) [9] => Array ( [title] => International Events [page] => 40 ) [10] => Array ( [title] => Submission guidelines [page] => 41 ) [11] => Array ( [title] => Imprint [page] => 42 ) ) [toc_html] =>

Table of contents

[toc_titles] =>

[cached] => true )