Endo Tribune U.S. No. 9, 2013
Avoiding blockages and breakages in endodontics / Industry
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ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition
september/october 2013 — Vol. 8, No. 7
www.dental-tribune.com
Clinical opinion
Avoiding blockages and
breakages in endodontics
By Barry Musikant, DMD
Many of us perform endodontic procedures based on what we learned in dental
school. For a slightly older generation,
that generally means doing the entire
shaping process with K-files. More recent
graduates have been taught one of several rotating NiTi techniques. Employing
these instruments does not preclude the
use of K-files, but it limits their use to a
maximum of 20 in most situations.
After the K-files create the glide path,
rotating NiTi is used to increase the taper of the canal and perhaps to enlarge
the apical preparation. Employing these
techniques reduces hand fatigue and
creates a more predictable space for the
placement of what appears to be a wellfitting point. The increased flexibility of
NiTi over stainless steel allows the rotating instrument to prepare even a curved
canal space with less potential distortion
than stainless steel files.
What we learn at any given time represents a consensus of what is the best
approach. We should also be aware that
what we consider to be the best approach
is not necessarily an ideal approach. Anyone who has performed endodontics
knows the use of K-files, particularly in
curved canals, tends to impact debris,
resulting in loss of length and, in the attempt to regain that length, distortion
of the canal pathway to the outside wall.
The employment of rotary NiTi solves
the problem of hand fatigue and inadequate preparations, but it introduces
unpredictable instrument breakage.
Despite the shortcomings of K-files (the
major impetus for NiTi’s creation), they
are still used in a limited way prior to the
use of rotating NiTi. That is where things
presently stand. Those dentists employing a rotating NiTi system generally agree
that the combination of K-files and rotating NiTi works better than K-files alone.
The problems associated with both are
generally only evident when shaping
curved canals, and, even here, these prob-
Fig. 1: Radiograph showing separated NiTi
File. Photos/Provided by Barry Musikant, DMD
Fig. 2: Photograph showing flat-sided reamer
with horizontal flutes as compared to a
vertical fluted file design.
lems are reduced as one becomes familiar
with the systems’ limitations.
The above reality is a good scenario for
keeping the status quo intact or, at most,
making small metallurgical, design and
sequence changes over time to spike
the curiosity of dentists to keep buying
the manufacturers’ products. Yet at the
end of the day, the dentist is still confronted with two concerns that become
more pronounced as the complexity of
the cases increase — namely, blockages
and breakages. Experience reduces these
problems but results in canals that are
cleansed more conservatively, reducing
the effective debridement and irrigation
of the canal space.
On the one hand, employing rotating
NiTi improves the “look” of the fill and
simplifies the placement of obturation
material. On the other hand, rotating
Figs. 3–5: Radiographs showing the results of flat-sided reamers used in reciprocating motion.
NiTi markedly increases the incidence of
breakage (Fig. 1).1–3 At this point, it is important to make a distinction between
the use of stainless steel and NiTi. To
optimize the use of each, they must be
used in different ways. NiTi can rotate
around curves, shaping them in the process. Its clear advantage is that used in
rotation, the shafts of the instruments
are generally flexible enough to maintain the original canal curvature as it is
enlarged.
Any stainless steel instrument beyond
a 15 is too stiff to negotiate curved canals
without leading to distortions if used in
rotation. If confined to short amplitudes
of motion, 02 tapered stainless steel instruments can negotiate curved canals
without distortion, with the added advantage that short amplitudes of motion
eliminate the two causes of instrument
breakage: torsional stress and cyclic fatigue.
By appreciating that the different metals are optimally used in different ways,
we can then focus in on the details of
stainless steel, realizing that K-files are
not nearly as efficient as K-reamers, both
unrelieved and relieved (Fig. 1). The major flaw of K-files is the incorporation of
a large number of horizontally oriented
flutes along their length. This design leads
to excessive engagement along length, removal of dentin only upon the pull stroke
and impaction of debris when introduced
into the canal. Alternatively, while K-files
can be used with balanced force, another
shaping technique that employs short
arcs of motion, this technique has been
associated with the production of apical
micro-fractures in dentin.
If we substitute K-reamers, both unrelieved and relieved, for K-files, we will
now be using instruments that:
1) Are far more effective in shaving
canals when using a manual, watchwinding motion or engine-generated,
30-degree reciprocation.
2) Engage the canal wall far less because
of the smaller number of flutes and their
predominantly vertical orientation.
3) Shave dentin away from the canal
walls with far greater efficiency.
4) Are significantly more flexible.
5) Are far less likely to impact debris
apically. 4
6) Afford the dentist an increased tactile perception that allows him or her to
differentiate between a solid wall and a
tight canal.
7) Differentiate between a round and
oval canal.
It should be clearly understood that
when we substitute K-reamers, both unrelieved and relieved, for K-files, we are
changing the traditional approach to
canal shaping that has led to the implementation of rotating NiTi. We are doing
it to facilitate the creation of the glide
path in speed and predictability, but we
should also be aware that, unlike K-files,
there is no need to limit the usage of relieved K-reamers to sizes 20 and less. The
same ability to shape canals to a 20 is retained through 40 and higher, creating
apical canal spaces without the need for
greater tapered rotating NiTi instrumentation.
Certainly, the stainless steel relieved
reamers are becoming stiffer, but not
nearly as stiff as their K-file counterparts.
Furthermore, confined to a short arc
of motion, the superior tactile perception these instruments provide lets the
dentist know if and when the tip of the
instrument is hitting a wall rather than
binding in a tight canal. With the clear
indication that an impediment is being encountered, the dentist knows precisely when to remove the instrument,
pre-bend it and then negotiate manually
around any blockage that may be present.
In short, these instruments are designed to first recognize any blockage
that might be present and then negotiate around that blockage. They are specifically not designed to create blockages.
The implications of the differences in
design between the K-file and K-reamers,
both unrelieved and relieved, cannot be
overemphasized.
Where K-files must be substituted for
as early as possible, the K-reamers, both
unrelieved and relieved, require no substitution. Their continued use with both
a tight, manual, watch-winding motion
or in the 30-degree reciprocating handpiece virtually eliminates instrument
breakage. Predictable non-breakage leads
to several additional benefits, including:
1) Multiple use of the instruments prior
to replacement with substantial savings.
” See ENDODONTICS, page B2
[2] =>
B2
“ ENDODONTICS, Page B1
2) Their aggressive usage in both the
mesio-distal and bucco-lingual planes of
oval canals.
3) Their elimination of the dentinal
micro-fractures associated with rotating
NiTi.
4) The elimination of “threading,” a process associated with rotating NiTi that tends
to apical overextension of the instrument
beyond the confines of the canal.
Recognizing the benefits to the easier
placement of obturation material that result from greater tapers, the last instrument in the series of relieved K-reamers
is often a 25/06 that imparts a taper that
allows for the predictable placement of
a medium gutta-percha point. Yet like
the other instruments in the sequence,
the 25/06 NiTi relieved reamer is used in
the 30-degree reciprocating handpiece,
virtually eliminating any chance of inAD
clinical opinion
strument breakage or dentinal microfracture production.5–6
Many benefits result from substituting K-reamers, both unrelieved and relieved, for K-files. They are not only far
more functional, but they actually preclude the need for rotating NiTi and its
mixed bag of benefits and drawbacks.
The most basic improvements are the
virtual elimination of self-imposed
blockages and unpredictable breakages.
Such improvements reduce procedural
stress and increase our capacity to tackle
more challenging cases with confidence.
Figures 3–5 show examples of these improvements.
One way to experience the advantages
discussed here is to set up a free, twohour, one-on-one workshop with me at
my endodontic office in Manhattan. For
those interested, call (212) 582-8161 and
ask for Evelyn. The classes are on a firstcome, first-served schedule and fill up
quickly.
Endo Tribune U.S. Edition | September/October 2013
Barry Lee Musikant,
DMD, FICD, is a member of the American
Dental
ENDO TRIBUNE
Association,
American Association
of Endodontists, Academy of General Dentistry, the Dental Society of New York, First
District Dental Society, Academy of Oral
Medicine, Alpha Omega Dental Fraternity and the American Society of Dental Aesthetics. He is also a fellow of the American
College of Dentistry (FACD). He is a partner in
the largest endodontic practice in Manhattan.
Musikant’s 35-plus years of practice experience
have established him as one of the top authorities
in endodontics. To find more information from
Musikant, visit www.essentialseminars.org, email
info@essentialseminars. org or call (888) 542-6376.
Note: A complete list of references is
avaialable from the publisher.
Publisher & Chairman
Torsten Oemus t.oemus@dental-tribune.com
President/CEO
Eric Seid e.seid@dental-tribune.com
Group Editor
Kristine Colker k.colker@dental-tribune.com
Editor in Chief ENDO Tribune
Frederic Barnett, DMD barnettF@einstein.edu
Managing Editor ENDO Tribune
Fred Michmershuizen
f.michmershuizen@dental-tribune.com
Managing Editor
Sierra Rendon s.rendon@dental-tribune.com
Managing Editor
Robert Selleck, r.selleck@dental-tribune.com
Product/Account Manager
Jan Agostaro j.agostaro@dental-tribune.com
Product/Account Manager
Humberto Estrada h.estrada@dental-tribune.com
Marketing director
Anna Kataoka-Wlodarczyk
a.wlodarczyk@dental-tribune.com
Education DIRECTOR
Christiane Ferret c.ferret@dtstudyclub.com
Tribune America, LLC
116 West 23rd Street, Suite 500
New York, NY 10011
Phone (212) 244-7181
Fax (212) 244-7185
Published by Tribune America
© 2013 Tribune America, LLC
All rights reserved.
Tribune America strives to maintain the utmost accuracy in its news and clinical reports. If you find a
factual error or content that requires clarification,
please contact Managing Editor Fred Michmershuizen
at f.michmershuizen@dental-tribune.com.
Tribune America cannot assume responsibility for
the validity of product claims or for typographical errors. The publisher also does not assume responsibility for product names or statements made by advertisers. Opinions expressed by authors are their own
and may not reflect those of Tribune America.
Editorial Board
Frederic Barnett, Editor in Chief
Dr. Roman Borczyk
Dr. L. Stephen Buchanan
Dr. Gary B. Carr
Prof. Dr. Arnaldo Castellucci
Dr. Joseph S. Dovgan
Dr. Unni Endal
Dr. Frnando Goldberg
Dr. Vladimir Gorokhovsky
Dr. Fabio G.M. Gorni
Dr. James L. Gutmann
Dr. William “Ben” Johnson
Dr. Kenneth Koch
Dr. Sergio Kuttler
Dr. John T. McSpadden
Dr. Richard E. Mounce
Dr. John Nusstein
Dr. Ove A. Peters
Dr. David B. Rosenberg
Dr. Clifford J. Ruddle
Dr. William P. Saunders
Dr. Kenneth S. Serota
Dr. Asgeir Sigurdsson
Dr. Yoshitsugu Terauchi
Dr. John D. West
Tell us what you think!
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[3] =>
Endo Tribune U.S. Edition | September/October 2013
industry
B3
Komet USA’s new F360 files reduce preparation time
The Komet® F360™ endodontic file system permits preparation of most root
canals with a simplified, time-saving
sequence requiring only two files, according to the company. Highly flexible
to minimize canal transportation, the
files feature a unique S-curve design and
a thin instrument core to deliver a high
level of cutting efficiency while respecting natural root canal morphology.
Only two files in sizes 025 and 035 are
required for most root-canal preparations. Their 0.04 taper promotes optimal
debridement of the canal, maintains file
flexibility and thus reduces preparation
errors and permits ideal shaping of the
root canal for subsequent obturation with
any method, according to the company.
The F360 files are employed in a torque-
Calasept
Irrigation
Needles
Calasept Irrigation Needles, available
from Wykle Research, are double-sidevented, luer-lock irrigation needles that
optimize the cleansing of canals, creating
a “swirl effect.” The needles are available
in 27 g or 31 g, in packs of 40 needles. Features include the following:
• Bendability
• Luer-lock hub
• Sterile and disposable
• Designed for ease in cleaning roots
• High-quality stainless steel
Also available are Calasept Irrigation
Syringes, which are color-coded to eliminate risk when using multiple irrigation
liquids. They are available in packs of 20
syringes, 10 white and 10 green.
These
products
complement
Wykle’s Calasept line, which includes
Calasept and Calasept Plus calcium hydroxide paste for temporary filling of root canals.
The Calasept products are manufactured
by Nordiska Dental of Sweden.
For more information, contact Wykle
Research at (800) 859-6641 or visit www.
wykleresearch.com.
(Source: Wykle Research)
Calasept Irrigation Needles.
Photos/Provided by Wykle Research
Calasept Irrigation Syringes.
limited motor and used in a picking
motion up to a predetermined working
length. The same torque (1.8 Ncm) and
speed values (250-350 rpm) are utilized
for all files; doctors need not adjust speed
or torque upon changing files during the
preparation sequence.
In addition to sizes 025 and 035, the
F360 files are offered in sizes 045 and 055
to meet additional clinical situations such
as wide roots, and all F360 files are available in three lengths (L21, L25 and L31) to
address varying coronal requirements.
The pre-sterilized, single-use files are designed to prevent cross-contamination;
eliminate the need to clean, disinfect, and
sterilize the instruments; and reduce the
risk of fracture due to cyclic fatigue.
Available in a sterile blister pack of six
files of a single size and length, the files
are supplied with a user’s manual and
step-by-step instructions.
About Komet USA
Currently celebrating its 90th year in
the dental industry, Komet is a recognized
worldwide leader in the production of
highly specialized, precise dental rotary
instruments. Komet operates in the United
States under the name Komet USA. Komet
sells direct to dental practitioners and dental laboratories. The company’s U.S. headquarters is located in Rock Hill, S.C. For
more information about Komet USA or the
F360 endodontic file system, call (888) 5663887 or visit www.komet-usa.com.
(Source: Komet USA)
Komet USA’s new F360 two-file system is
designed to be simple.
Photo/Provided by Komet USA
AD
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