Endo Tribune Middle East & Africa No. 6, 2016
Providing ease of use - resistance to cyclic fatigue - swiftness and effectiveness - the new XP-endo® / Twisted-Files Adaptive: A Novel Approach to Endodontic NiTi Instrumentation
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DTMEA_No.6. Vol.6_ET.indd
www.dental-tribune.me
Published in Dubai
November-December 2016 | No. 6, Vol. 6
ENDO TRIBUNE
Providing ease of use, resistance to cyclic fatigue,
swiftness and effectiveness, the new XP-endo®
Shaper is the amazing
single-file
system
developed
by FKG
SA
The World’s
Endodontic
Newspaper
Middle
EastDentaire
& Africa Edition
By FKG
The XP-endo® range of instruments
is designed to facilitate the clinicians’
practice, while maximising endodontic treatment quality and safety.
The XP-endo® Shaper provides the
general dentists, as well as the specialists, with a very innovative endodontic file.
This broad-spectrum instrument is
indicated for the shaping of the vast
majority of root canals:
- Manufactured using the patented
MaxWire® alloy, the XP-endo® Shaper features extreme flexibility and
remarkable fatigue strength, compared to competitive instruments of
the same final size. It has the capacity
to expand and the ability to progress
with agility within the canal, with
Thanks to its small core diameter,
its cutting efficiency and the stream
generated in the irrigation fluid,
large amount of dentine micro-debris are evacuated efficiently. This
prevents the risk of debris compaction into canal irregularities, as well
as it limits the risk of extrusion beyond the apex.
Shaper has a gentle, non-aggressive
action and promotes conservative
procedures.
Used after preparing a glide path to
minimum ISO 15/.02, it allows reaching a final canal preparation of at
least ISO 30/.04.
Available in 21, 25 and 31 mm lengths,
the XP-endo® Shaper is packed in
sterile blister of 6 instruments.
With this new instrument, FKG Dentaire supports general dentists and
endodontists to perform the root
canal shaping simply, quickly, safely
and with just one instrument.
Available from September 2016
a reduced risk of torsional fatigue.
From its initial .01 taper, the XP-endo® Shaper can expand to achieve a
minimum .04 taper.
- Equipped with the Booster Tip (BT),
offering 6 cutting edges, the XPendo® Shaper starts shaping at ISO
diameter 15 and then increases its
working scope to achieve ISO diameter 30.
The BT tip maintains the instrument centered and avoids ledging or
straightening of the root canal.
These technical advantages combined with high-speed continuous
rotation and minimum torque,
minimise the stresses exerted onto
the canal walls and prevent the risk
of micro-cracks. The XP-endo®
FKG Dentaire SA
Crêt-du-Locle 4
CH-2304 La Chaux-de-Fonds, Switzerland
T. +41 32 924 22 44
info@fkg.ch | www.fkg.ch
3D agility_
The One to Shape your Success
FKG Dentaire SA
www.fkg.ch
[2] =>
DTMEA_No.6. Vol.6_ET.indd
A2
endo tribune
Dental Tribune Middle East & Africa Edition | 6/2016
Twisted-Files Adaptive:
A Novel Approach to Endodontic NiTi Instrumentation
By Dr. Adi Moran, UK
A major goal of Endodontics is the
prevention or elimination of “apical
periodontitis”. Apical periodontitis
is the general term for endodontic
related periradicular/periapical inflammation, whether it is histologically a granuloma, cyst or abscess,
in symptomatic or asymptomatic
form.1 When root canal treatment is
indicated, we rely on the triad of instrumentation, irrigation and obturation to achieve this goal.
Instrumentation has come a long
way since we first started using NiTi
alloy in root canal preparation. Initially research concentrated mostly
on features of file design such as taper, cross section, blade rake angle,
pitch, tip design and so on. We then
went on to improving the metallurgical properties of NiTi alloys for
even more enhanced flexibility and
fracture resistance. More recently
we started also researching kinematics of NiTi files in root canals in the
search of optimised preparation.
Today we know a lot about advantages and disadvantages of features
from all these three categories
through the vastly accumulated evidence based research. ‘TF-Adaptive’,
as a motor and file system, was brilliantly designed with a focus on
providing the clinician with a huge
set beneficial features at hand while
greatly reducing the potential limitations. During canal preparation the
system shifts automatically between
file rotation motion and reciprocation, each when most desired and
appropriate.
This in turn results in an ability
to safely prepare root canals – file
separation almost worry free – not
only quicker then before but also respecting the original canal trajectory,
improving circumferential canal
preparation and greatly minimising
debris extrusion compared to other
reciprocating systems.32
Rotation vs. reciprocation
From the 90s,“traditional” NiTi root
canal instrumentation has been
done through continuous instrument rotation. More recently, Yared
introduced the concept of canal instrumentation using a single NiTi
file using reciprocation movement.2
Since then, reciprocation has been
the focus of much research and designated motors and NiTi files have
been brought to market. The benefits
of reciprocation helped in making
these file systems quite popular.
In time, independent research has
shed more light on these advantages but also on disadvantages when
comparing root canal preparation
by reciprocation with the traditional
continuous rotation. We now know
that when considering some important aspects, continuous rotation
remains superior to reciprocation,
while the opposite is true when considering other aspects.9,13-16 TF Adaptive is the only system to smartly
empower the clinician with both features in one single program mode.
It does this by a sophisticated automatic torque algorism that uses rotation when we want it and reciprocation when we need it. The system
does this skillfully, eliminating the
need for clinicians to switch between
the programme settings on the endo
motor during canal shaping.
In a reciprocating movement the
file rotates in one direction, engaging and cutting the dentin, and then
rotates back to a lesser degree, disengaging from the dentin. This extends
the cyclic fatigue resistance on the
file, reducing stress on the instrument to a degree where it is possible
to prepare the entire root canal using
a single NiTi file.12,17,11,23,25 This is usually not possible when using NiTi
files in a continuous rotation motion
and serves as a strong selling point to
preparation by reciprocation vs. by
rotation.
The other major advantage of reciprocating movement is the ability to
better preserve original canal trajectory (Fig 1.).16,26 This is attributed to
overall lower instrumentation stress
applied on canal walls. However,
other factors need consideration
too and rigid files or ones with cutting tip designs would (negatively)
greatly affect and promote transportation, even when a file reciprocates.
It can also be argued that preparing
canals with a single NiTi file is simpler and to some degree might be
quicker.18,19,20
On the other hand preparation by
pure reciprocation is known to increase the incidence of post-operative pain, brushing laterally may be
less efficient, less emphasis is given
to the straight line coronal access
(pre-flaring) phase of preparation
and also apical enlargement is not
always addressed by a single NiTi file.
1. Increased incidence of post-operative pain is due to significantly
greater debris pushed out as a consequence of the file movement in
a full reciprocating mode.9,32 This is
true for vital cases and even more so
when, in non vital cases, the debris
being pushed out is infected.22 On
the other hand, in pure rotation, file
flutes are designed to push debris
upwards away from the apex, resulting in significantly less debris pushout.21,19
2. After shaping to entire canal
length and reaching the master apical file, we want to brush laterally to
achieve as much main canal circumferential cleanliness as possible in an
asymmetric oval canal where our
instrument is round and centered.
Rotation with ultra flexible files
(such as Twisted Files) with effective
cutting blades does this job more
efficiently than with a reciprocating
motion.4,29,30 This is achieved beautifully using the TF Adaptive System
in the “TFA Program Mode”. Given
the width of the canal at this stage,
the file works in rotation only with
low torque applied on it. The same
could be achieved also by switching
to the pure “Twisted File Full Rotation Mode” at a push of a button on
the motor.
3. Single file endodontics is not always advised, especially when treating molar teeth where different
canals of the same tooth may vary
greatly in dimensions. For example,
a single reciprocating file size 25 with
taper .08 might be sufficient when
preparing MB1 and DB canals of an
upper first molar tooth. Yet in most
cases this file size would not be as
compatible for MB2 canals, and certainly not compatible for the P canal
of the same tooth. In such cases, if a
single reciprocating file is used, we
may need to resort at a later stage to
the step back or other rigid files techniques for apical enlargement. This
is still far less beneficial than simply
using several highly flexible NiTi files
Fig. 2. TFA-SM1
Fig. 1. High degree curvature in apical third of distal root canal.
Fig. 3. TFA-SM1 kept at a pre-bent state with help of cold spray.
Fig. 4. Referred case with ledge in apical
third of mesial canal
Fig. 5. 1 year review. Ledge was managed
with pre-bent SM2. Healing apical tissues.
of various taper and apical dimensions to tailor our needs and combat
each canal more specifically, without
compromise. The TF Adaptive System lets us decide during each case
whether to complete the work using
a single NiTi file or to adapt with one
or two more files. The “bigger” files
(yellow and then red) are designed
with enlarged apical size but with reduced taper. They therefore remain
highly flexible despite being bigger
in size.10 This feature is important
when the canal is highly curved but
at the same time a greater size apical
enlargement is required. This is easily and safely done with the apically
wider yellow and red TFA files after
the smaller green one (ML1) took care
of the taper in the coronal two thirds
of the canal.
4. Lastly, there is the misconception
about pure reciprocating systems
being truly single NiTi endodontics,
where in reality it is recommended
to firstly produce a glide path wide
enough to require up to three more
files, which may be NiTi ones.33, 34
need to actually reduce the temperature in order to shift into the
Martensite phase. Manufacturing
under R-Phase gives the file properties which allow us to cool a file chairside with a conventional endo cold
spray to a temperature range where
the NiTi file stays bent long enough
for us to precurve the file, like we do
with stainless steel ones (Fig. 2 and
3).8,25 This is greatly beneficial when
managing ledged root canal cases
(Fig. 4).
R-Phase technology
NiTi alloys are super elastic (highly
flexible) and have shape memory
(return to original shape after flexing) due to a reversible atomic crystal lattice shift between the Austenite and deformed Martensite states.
This atomic shift happens when
external tension is applied on the file
by the root canal.24
However, the ability to create this
atomic shift also depends on ambient temperature and on the alloy’s
thermal pre-treatment during the
manufacturing of the endodontic
file. Manufacturing with specific
thermal pre-treatment, (know as
R-Phase), further contributes to the
ability of the NiTi file to absorb stress
and resist fatigue resulting in greatly
enhanced file flexibility compared to
NiTi’s manufactured with traditional
techniques. Twisted Files are manufactured by twisting the raw material
to shape during a thermal cycle that
transforms into the R-Phase.7
As mentioned above, the reversible
atomic confirmation also depends
on ambient temperature. It is interesting to note that at room temperature, the atomic file confirmation
is in the stable Austenite phase. We
Until this technology came along,
the conventional approach for ledge
management required extra work
and chair-time using one pre-curved
stainless steel files after the other.27
Without doing this first the normal
NiTi file would go naturally into and
stop at the ledge point. Even more so,
the very severe ledges could not be
“cancelled” well enough with stainless steel. These cases required the
continuation of canal preparation to
master apical file without being able
to use NiTi files at all.
Having cooled the TF Adaptive File
with a cold spray, we pre-bend the
file, quickly insert it with a tactile
hand motion beyond the ledge,
then connect it to the headpiece and
choose to either first brush laterally
in an anti-curvature up/down motion trying to cancel the ledge as
much as possible, or continue with
gentle downpecking apically instead.
It is also important to note that canals with problematic ledges which
were effectively prepped to length
with NiTi files are easier to obturate
with the continuous wave of obturation warm technique, as opposed to
those prepped with stainless steel
alone.
Innovative file design28
Twisted Files are the only files in the
market manufactured in the same
way as stainless steel ones, by twisting them into shape. This is done
during the thermal cycle that transforms into the R-Phase.
• The result is a smooth and continuous file surface. All other NiTi files are
grounded into shape. The machining
process leads to machining grooves
on the surface of the file. File fracture always starts at the weakest link.
These machining surface grooves
Fig. 6. Double curvature management
with reduced risk to file separation in the
second curve.
serve as initiation points for cracks
and then possibly file fracture.31
• In addition to twisting, Twisted
Files then further undergo a process
of surface deoxidation for even more
enhanced surface smoothness.5, 6
• The Twisted Files’ cross section is a
triangular one. This results in effective dentin cutting allowing us to use
the same file both as a reamer and
then later as a Hedstrom file to effectively brush laterally.
• The Twisted Files’ pitch configuration varies along the file rather than
being constant. This reduces the
“pull-in” effect and creates smooth
tracking during root canal preparation.
• The Twisted Files’ tip is a safe ended
non cutting pilot. The tip guides and
does not dig. This helps in reducing
occurrences of canal transportations.
The TF Adaptive way
Operator use feels ‘different’ compared to pure rotating modes, yet
the overall learning curve is quick
and you get to love the entire system
very soon.
The system is designed to shift automatically between interrupted rotation to start with and reciprocation.
The rotation reaches 600 degrees
then stops and restarts to a new 600
degrees loop. This gives the benefits
of rotation, i.e better cutting and debris being pushed upwards. With increased load further down the canal
and beyond the curves, the system
will then gradually shift to varying
reciprocation angles, as required.
This is different to the traditional
reciprocation systems with constant
clockwise/counter clockwise angles.
Under higher torque stress, TF Adaptive rotates 370 degrees clockwise
and up to 50 degrees counterclockwise. This provides further safety
against file separation and canal trajectory is highly respected (Fig. 5 and
6).10, 32 The ML (Medium Large) file set
is a true crown-down technique. The
taper of the first file facilitates better
irrigation while the next ones work
more on apical enlargement. The SM
(Small) set manages sclerotic cases.
Clinical tips
Following access cavity preparation,
achieving straight line access is an
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DTMEA_No.6. Vol.6_ET.indd
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endo tribune
Dental Tribune Middle East & Africa Edition | 6/2016
◊Page A2
important step prior to inserting
a file and measuring the working
length. Next, achieving a glide-path
is important. In the ML set, the green
file .08/25 will usually do most of
the work in the canal. It is tempting
for the clinician to peck it up/down
apically all the way to working length
in one go because the system is efficient and therefore in many cases
capable of doing so. Avoid doing
this and once the file engages dentin, take it out to clean flutes, irrigate
the canal and remember to maintain
recapitulation. File unwinding is unlikely to occur if the above rule is followed. However, in rare cases when
it does happen, it should serve as a
unique cautionary sign before file
separation, and as a warning to the
operator that the hand pressure applied apically on the handpiece was
higher than advised.
After ML1, the ML2 .06/35 will often
go effortlessly straight to working
length. This is greatly beneficial for
apical enlargement, reduces the
risk of file separation. Depending
on original canal size/complexity,
this is also true when ML3 is needed.
Achieving MAF (master apical file) of
ML2 (.06/35) also means we can use
an EndoVac irrigation system to better disinfect the root canal system.
After MAF is achieved, I prefer final
lateral brushing in the regular “TF
Full Rotation Programme Mode”
however this can also be done in the
“TF Adaptive Mode”. The file will feel
minimal torque and therefore brush
in interrupted rotation 600-0 degrees and not reciprocation eciprocation.
References
1. Hummonen S, Orstavik D. Radiological aspect of apical periodontits.
Endod Topics 2002;1:3-25
2. Yared G. Canal preparation using
only one Ni-Ti rotary instrument:
preliminary observations. Int Endod
J 2008;41:339–44.
3. Phase-transformation temperatures of TF were signifi- cantly higher
than those of machined files, with
the bending load values being significantly lower for these files in
the elastic and SE ranges (Hou et al.
2011). Hou XM, Yahata Y, Hayashi Y,
Ebihara A, Hanbawa T, Suda H (2011)
Phase transformation behavior and
bending property of twisted nickeltitanium instruments. International
Endodontic Journal 44, 253–8.
4. Hulsmann M, Peters OA, Dummer
PMH (2005) Mechanical preparation
of root canals, shaping goals, techniques and means. Endodontic Topics 10, 30–76.
5. Bahia MGA, Buono VCL (2005)
Decrease in the fatigue resistance of
nickel-titanium rotary instruments
after clinical use in curved canals.
Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontology 100, 249–55.
6. Anderson ME, Price JW, Parashos
P (2007) Fracture resis- tance of electropolished rotary nickel-titanium
endodontic instruments. Journal of
Endodontics 33, 1212–6.
7. Gambarini G, Gerosa R, De Luca
M, Garala M, Testarelli L (2008a)
Mechanical properties of a new and
improved nickel-titanium alloy for
endodontic use: an evaluation of file
flexibility. Oral Surgery Oral Medicine Oral Pathology Oral Radiology
and Endodontology 105, 798–800.
8. Otsuka K, Ren X (2005) Physical
metallurgy of Ti-Ni-based shape
memory alloy. Progress in Materials
Science 50, 511– 678.
9. Burklein, Dr med dent, and Edgar
Schafer, Prof Dr med dent. Apically
Extruded Debris with Reciprocating
Single-File and Full-sequence Rotary
Instrumentation Systems Sebastian
JOE — Volume 38, Number 6, June
2012 850-852
10. G. Gambarini1, R. Gergi2, A.
kinematics rotary nickel-titanium
systems. J Endod 2013; 39:906–9.
TF-Adaptive as a complete system (motor+files) combines
superior features from all fronts of endodontic instrument
science, i.e. file movement kinematics, file shape and metallurgy, taking us to the next level in perfection of root canal preparation. It gives me confidence to prepare highly
curved canals without the fear element of file separation,
while operating so much quicker then ever before.
The outcome is enhanced circumferential canal preparation for better irrigation and reduced extruded debris related postoperative pain. I absolutely love working with it.
Naaman2, N. Osta2 & D. Al Sudani3.
Cyclic fatigue analysis of twisted file
rotary NiTi instruments used in reciprocating motion. Int Endod Journal 2012 1-5.
11. Vadhana S, SaravanaKarthikeyan
B, Nandini S, Velmurugan N. Cyclic
fatigue resistance of RaCe and Mtwo
rotary files in continuous rotation
and reciprocating motion. J Endod
2014;40:995–9. 14.
12. Gavini G, Caldeira CL, Akisue E, et
al. Resistance to flexural fatigue of
Reciproc R25 files under continuous
rotation and reciprocating movement. J Endod 2012;38: 684–7. 15.
13. Goldberg M, Dahan S, Machtou
P. Centering ability and influence of
experience when using WaveOne
single-file technique in simulated
The complete list of references is available from the publisher.
canals. Int J Dent 2012; 2012:206321.
14. Lim YJ, Park SJ, Kim HC, Min KS.
Comparison of the centering ability of Wave.One and Reciproc nickeltitanium instruments in simulated
curved canals. Restor Dent Endod
2013;38:21–5
15. Marzouk AM, Ghoneim AG. Computed tomographic evaluation of canal shape instrumented by different
Dr. Adi Moran, is a
board certified specialist in Endodontics.
He works in London
in the Harley Street
Dental Group and in
EndoCare. His practice
is exclusively referral
based limited to Endodontics. Adi is a ‘key
opinion leader’ for Kerr Endodontics. He
routinely lectures in Endodontics nationally and internationally and has been an
‘associate clinical teacher’ for 5 years at
the Faculty of Endodontics, the University
of Warwick instructing MSc courses.
Essential Dental Media
Dental Tribune International
The World’s Largest News
and Educational Network
in Dentistry
www.dental-tribune.com
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