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Endod Dent Traumatol 1997; 13: 51-64 Printed in Denmark .

Ait rights reserved

Copyright Munksgaard

1997

Endodontics & Dental Traumatology


ISSN 0109-2502

Review article from invited author

Root canal instruments for manual use: a review


Schafer, E. Root canal instruments for manual use: a review. Endod Dent Traumatol 1997; 13: 51-64. Munksgaard, 1997. Abstract - Root canal instruments ean be subdivided into instruments made of different alloys (stainless steel, nickel-titanium and nickel-aluminium) and instruments with different geometric forms (e. g., instruments with short cutting segments). Several types of stainless steel and titanium-based instruments are presented and assessed by a review of the current literature. In summary, flexible stainless steel instruments with noncutting tips seem to be a decisive improvement in the development of an ideal root canal instrument. They are superior to titanium-based instruments in both cutting efficiency and instrumentation of curved root canals. E. Schafer
Zentrum fiir Zahn-, Mund- und Kieferheilkunde, Poliklinik fii Zahnerhaltung, University of Miinster, Munster, Germany

Key words: endodontic hand instruments; nickeititanium instruments; root canal instruments; stainless steel instruments Edgar Schafer, Poliklinik fur Zahnerhaltung, Waldeyerstr. 30, D-48149 Munster, Germany Accepted October 18, 1996

The results achievable by root canal treatment still depend critically on the method of preparing root canals and on the instruments used for enlarging the canals. Nowaday, success rates of about 80% are reported for root canal treatment (1). Successful endodontic treatment depends on accurate diagnosis and adequate cleaning and shaping of the root canals. Unfortunately, the latter is not easily achieved, particularly in curved canals. Although remarkable improvements have been made concerning endodontic hand instruments and a variety of new instruments have been designed, it is quite difficult for the dentist to judge objectively the abilities of all these instruments. Therefore, based on a review of the relevant literature, conventional root canal instruments and subsequent modifications will be presented and discussed in detail. Concerning root canal instruments for manual use, two major innovations have been made during recent years: first, highly fiexible instruments made of new alloys like nickel-titanium have been developed and second, new geometrical shapes, such as modified instrument tips or instruments with short cutting segments, have been introduced. In principle, root canal instruments can be subdivided into three different types. These are reamers, K-files^ and Hedstrom files

(2). Several modifications to these three types have been displayed in the last years (3, 4), and in the following, these types of instruments will be presented and assessed. Stainless steel root canal instruments Conventional root canal instruments Until 1960 root canal instruments were produced of carbon steel. Nowadays stainless steel alloys are universally used (5). It is said that modern stainless steel alloys as compared with older carbon steel alloys can be sterilized largely without detrimental physical changes. Stenman (6) observ^ed the effect of sterilization on the cutting efficiency and resistance to fracture of both carbon steel and stainless steel root canal instruments. His results demonstrated that sterilization can lead to considerable corrosion damage to carbon steel instruments, whereas no significant effects on the mechan-

' The K-type instruments were first introduced at the beginning of the century and designed by the Kerr Manufacturing Co. (Romulus, Michigan, USA) (2). In 1915 Kerr patented aU K-type instruments (4).

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Schafer ical properties of stainless steel instruments were observed. Whether the cutting efficiency of root canal instruments is affected by different sterilization techniques was discussed with some controversy. Several authors demonstrated that different sterilization procedures of stainless steel instruments produced surface changes resulting in a decrease in cutting efficiency (7, 8) and microhardness (9). On the other hand some authors observed no decrease in the cutting efficiency of stainless steel instruments after several sterilization cycles (6, 10, 11). Younis (12) published a study on the effects of sterilization on the torsional properties of both carbon and stainless steel instruments. It was demonstrated that sterilization caused a decrease in the torque and angular deflection of carbon steel instruments. In further studies no effects of sterilization on the torsional and bending properties of stainless steel instruments were observed (13, 14). Recently, Scott et al. (15) conducted an investigation on sterilization effects on stainless steel and carbon steel instruments. Certainly, corrosion is rare on stainless steel instruments but, nevertheless, even modern stainless steel instruments show isolated corrosion damage. The authors concluded from their results that corrosion of stainless steel instruments depends more on variations in manufacturing procedures than on differences in metallurgy. The properties of stainless steel endodontie hand instruments will be discussed in the following, on the basis of a review of the relevant literature. K-reamers - Depending on manufacturer and ISO size, reamers are made from square or triangular blanks (2). Because they are twisted to give the working end of the instrument a spiral form, the integrity of the blanks will not be damaged, resulting in high resistance to torsional fracture (16, 17). Reamers have 1/2 to 1 cutting blades per mm of their working end, and thus have fewer cutting blades than the K-file (2, 3). The angle of the blades to the long axis of the reamer is about 10 to 30 (18), hence these instruments are primarily designed to be used in a rotary reaming motion (2, 3, 16). They cut by being inserted into the canal, twisted about one-quarter turn clockwise to engage their blades into the dentine, and then withdrawn (2, 18). The core diameter of any root canal instrument affects its flexibility as well as its resistance to fracture (2). Due to a well-balanced relation between core diameter and resulting area for debris removal, reamers have sufficient resistance to fracture and flexibility and at the same time sufficient cutting efficiency (2, 19, 20). Reamers are the only instruments that produce a round, tapered preparation, mainly in perfectly 52 straight canals (3, 19, 20). Concerning the enlargement of curved canals, reamers may cause undesirable transportation or straightening of the canal, especially in canals with ovoid cross-sections (3, 16, 18, 21, 22). Finally, according to several authors, the sole use of reamers seems not to be recommendable, either in straight or in curved canals (2, 18, 20, 22, 23). Cohen & Burns (3) state that "aside from being slightly more flexible and less susceptible to fracture, K-type reamers offer no advantage over K-type flies". K-Jiles - K-flles, like reamers, are twisted instruments made from square or triangular blanks, depending on their ISO size and manufacturer (2). Moreover, K-files and reamers have a relatively high resistance to torsional fracture (17). Compared to reamers, K-flles show 1V2 to 2'A cutting blades per mm of their working end; thus there are about twice the number of spirals on a K-flle as on a reamer of a corresponding size (2, 4, 16). The average resistance to bending of K-flles is less than that of reamers. Concerning torque and angular deflection, in most cases K-flles reach greater angular deflection than reamers of the same brand (17). The greater resistance to fracture of K-flles has a direct clinical impact. Under clinical conditions, the angular deflection gives some information about the risk that an instrument which bends at its tip will fracture if it is rotated any further. Hence, under clinical conditions the risk of torsional fracture is less for K-flles than for reamers. The tighter spiral of a K-flle establishes a cutting angle, e. g. an angle of the flutes to the long axis of the K-flles, that is about 25 to 40; thus these instruments are, like reamers, primarily designed to be used in a rotary reaming motion (2, 18). Distinct transportation of canals is reported (22, 24) when using K-flles with a rotational cutting action in combination with a longitudinal flling motion. Jungmann et al. (25) compared the shaping abilities of K-flles using a reaming motion and using a linear flling motion. They report that canal enlargement with a reaming motion proved better than with a linear filing motion. In contrast to this, other authors state that shaping of curved canals with K-flles manipulated in a linear flling motion proved a satisfactory method to maintain the original canal curvature (2, 16, 23). Alodeh & Dummer (26) also investigated the ability of K-flles used with a flling motion to shape simulated curv^ed canals and found that K-flles created pronounced zips and elbows and removed an excessive amount of resin from the inner aspect of the canal curves. This had already been observed by Cimis et al. (27) in extracted human molars. According to other authors an alternate use of reamers and K-flles appears to be an effective prep-

Endodontic hand instruments aration technique, particularly in curved canals (2, 4, 20, 28, 29). Hedstromfiles- The cutting blades of Hedstrom files, U-files, and Helifiles are machined into a round blank (4, 30). Thus, the fiutes of the Hedstrom file constitute a spiral like a screw (30). Hedstrom files are characterized by an approximately circular cross-section ("teardrop cross-sectional shape") and the periphery bears spiral grooves; whereas S- and U-files are sigmoid in cross-section (2, 4, 30). The flutes of U- and S-files are less deep than those of Hedstrom files (3). For Hedstrom files, the angle between the cutting edge and the long axis of the instruments is about 60 to 65; thus they are designed primarily for a linear, filing motion (2, 4, 18). Due to their positive rake angle they cut in one direction only, in a withdrawal stroke. Since these instruments are machined from circular cross-sectioned blanks, they have sharp cutting edges (2, 4). Used in linear motion, they are far more efficient than reamers or K~files, cutting away more root canal dentine than K-files (29-34). Compared to files with two or three spiral grooves, such as S- or U-files with their double-helix design, Hedstrom files display the best cutting efficiency in linear motion. The helical angle of Hedstrom files appears closer to 90 than S- and U-files; this may be an explanation for the better cutting efficiency of Hedstrom files in linear motion (29, 35, 36). Due to the manufacturing process of Hedstrom files, grinding cracks may result on the surface of the instrument. Hedstrom files and S- or U-files are unsuitable for use in a rotary reaming motion since, because they have a low core diameter and are milled from blanks, they show a higher risk of torsional fracture compared with reamers or K-files. That is why some authors do not recommend the use of milled instruments like Hedstrom files in narrow or curx^ed canals due to an assumed higher risk of fracture (17, 18, 24, 30). In general, U-files compared with Hedstrom files show a smaller angle between the cutting fiutes and the long axis of the instrument and at the same time lower fiute depth. Therefore, it is claimed that the shaping effects and cutting efficiency of U-files will be between those of reamers and files, as implicitly indicated by the name "Unifile". Their potential for both apical preparation by reaming and coronal fiaring by filing allows these instruments to be used as a universal instrument (3). According to Al-Omari et al. (37) Unifiles generally show a high risk of torsional fracture when used in curved or narrow canals. Instrumentation of curved canals using Hedstrom files or U-files is discussed with some controversy. While ElDeeb & Boraas (38) among others report that especially pre-curved Hedstrom files guarantee good instrumentation results in curved canals, other authors are opposed to the use of filing instruments down to the working length of curved canals (2, 18, 24, 26, 37). In particular, it has been demonstrated that the filing motion of Hedstrom files results in a severe straightening of the inner canal wall as well as an excessive material removal on the outer side of the curvature (18, 26, 37). Besides, the use of Hedstrom files results in significantly rougher canal walls, compared with other instruments (37). Moreover, due to the geometrical shape of the tip of Hedstrom files, it is quite impossible to prepare a defined apical stop with these instruments (18). But an effective apical stop against which a master gutta-percha cone of the same size as the final root canal instrument can be seated is required in any efficient root canal preparation (30). Alodeh et al. (39) and Al-Omari et al. (37) have done extensive investigations on the instrumentation of curved canals under standardized conditions. They report that filing motion with Hedstrom or U-files definitely results in undesirable shaping effects (such as the formation of zips or elbows) and furthermore leads to a marked shortening of the working length of the root canal of extracted human molars, with occasional complete blocking of the canal. All in all, several authors agree that stainless steel Hedstrom files will be the preferred instruments whenever a maximum of root canal dentine is to be taken oft a canal wall in a minimum of time. This will be the case during any preparation of straight canals (which occurs in a mere 10% of all cases) (40) or the conical enlargement of the coronal part of the canal

(2, 18, 29, V


Flexible stainless steel root canal instruments In order to avoid undesirable shaping effects in curved root canals, such as straightening, ledging, zip and elbow formation, several manufacturers have developed new stainless steel alloys characterized by higher fiexibility in bending compared with conventional stainless steel instruments (5, 41, 42). These so-called flexible stainless steel instruments are similar in shape to conventional reamers and Kfiles (22): Flexicut. In 1989 the VDW company (VDW, Munich, Germany) presented the Flexicut instrument at the International Dental Show. These instruments are made of a chrome-nickel steel (SCSstainless steel"^). They are triangular in cross-section and the working end shows 24 to 26 spirals (43), resulting in an angle of the cutting flutes to

SCS = Spacecraft steel

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Schafer the long axis of 24 at the tip region and 45 at the end of the working part (43). Flexoreamer. The Flexoreamer has been produced by Maillefer (Ballaigues, Switzerland) since 1981 in ISO sizes 15 to 40. The cross-section of this twisted instrument is triangular. Independent of instrument size the working end has 16 spirals (33). Hence, the angle between the cutting fiutes and the long axis is 23 at the tip region and 32 at the end of the working part of the instrument. When used in rotary reaming motion, the Flexoreamer displays by far the highest cutting efficiency of all hand instruments (43, 44). K-Flex file. In 1982 the Kerr Manufacturing Co. (Romulus, Michigan, USA) introduced a new instrument design, named the K-Flexfile(46). This instrument is fabricated of V-4 steel and the crosssection is rhombus-shaped to enhance fiexibility and cutting efficiency (4, 43, 45). The angle between the cutting flutes and the long axis is about 25 at the tip region and 50 at the end of the working part. Like K-files, the spirals of the K-Flex file are produced by twisting. Because of the rhombus-shaped cross-section "the cutting edges of the high flutes are formed by the two acute angles of the rhombus and present increased sharpness and cutting efficiency. The alternating low fiutes formed by the obtuse angle of the rhombus are meant to act as an auger, providing more area for increased debris removal" (4). Schafer et al. (44) have studied the cutting efficiency of K-Flexfilesand conclude that the K-Flex files display higher cutting efficiency than conventional stainless steel reamers, K-files and the fiexible Flexicut, but lower cutting efficiency than Flexoreamers and K-Flexofiles. K-Flexofile. The K-Flexofile, like the Flexoreamer, has been produced by Maillefer since 1981 in ISO sizes 15 to 40. The cross-section of this twisted instrument is triangular. Independent of instrument size the working end has 29 spirals (43). Hence, the angle between cutting fiutes and long axis is 30 at the tip region and 45 at the end of the working part of the instrument. When used in a rotary reaming motion, the K-Flexofile and the Flexoreamer display the highest cutting efficiency of all hand instruments (43, 44). The cross-section of the fiexible stainless steel instruments is triangular or rhombus-shaped, resulting in relatively low core diameters. Thus they showbetter cutting efficiency and enhanced fiexibility compared with conventional stainless steel instruments (17, 44). Concerning resistance to fracture, fiexible stainless steel instruments display less torque than most conventional stainless steel instruments; the angular defiection of these instruments is similar to that of conventional reamers and K-files (17). It has been shown in several studies that fiexible 54 stainless steel instruments display less resistance to bending than conventional stainless steel reamers and K-files (5, 17, 42). Therefore, the tendency of fiexible stainless steel instruments to straighten themselves in the curved canal is much less compared to conventional stainless steel instruments. Concerning their cutting efficiency in rotary motion, Schafer et al. (43, 44) have performed investigations under standardized conditions and report that flexible stainless steel instruments show significantly higher cutting effciency than any other instrument tested. Other reports in the literature also point to the high cutting efficiency of flexible stainless steel instruments (37, 40, 45). Moreover, reports in the literature agree that instrumentation of curved canals is more successful with flexible stainless steel instruments than with conventional reamers or K-files (22, 37, 38, 40, 46, 47). Briseno (24) reported a better canal shape of curved canals after manual preparation with flexible instruments, compared with conventional instruments. On the basis of extensive investigations, Al-Omari et al. (37) also demonstrated that canal shaping of curved canals with flexible instruments appears to be superior to that possible with conventional instruments. Nevertheless, even with flexible stainless steel instruments, enlargement of severely curved canals may lead to undesirable changes in the canal shape, as difTerent authors have shown (22, 47). Recently, interest has focused on instrument tip modiflcations. It has been found that especially the sharp cutting edges at the tip of conventional and flexible instruments have a significant influence on the instrumentation results. In curv^ed canals, due to the metallic memory, any stainless steel instrument has a tendency to straighten itself In this way sharp conventional tips may create ledges at the outer wall of the curvature, producing zips and bulging of the canal (22); this action takes place on the convex curvature of the canal. Conversely, instruments with modified noncutting tips will slide along the outer side of the curvature, staying centered within the original canal (Fig. 1, 2). Because of these considerations Roane et al. (48) developed the flexible Flex-R flle (Union Broach, Emigsville, PA, USA) with a parabolic noncutting tip. Subsequently, the Maillefer company has produced two flexible stainless steel instruments, both having a noncutting, so-called Batt-tip (18, 22, 43). Due to these tip modifications instruments with noncutting tips are expected to have better central guidance in the curved canal to avoid ledging and zipping (Fig. 1). The Flexoreamer and the K-Flexofile, both with a noncutting Batt-tip, are twisted instruments whereas the blades of the Flex-R file are machined from a blank (49). The angle of the flutes to the long axis of the Flex-R file is about 30 to 40, depending on the ISO size of the instrument (Fig. 1).

Endodontic hand instruments

Fig. 1. SEM microphotograph of flexible stainless steel root canal instruments size 35 with modified noncutting tips (original magnification X80): a) K-Flexofile (Maillefer), b) Flexoreamer (Maillefer), c) Flex-R file (Union Broach).

In the subsequent period, several investigations have been carried out on the effect of tip modifications. Powell et al. (50, 51) and Sabala et al. (52) confirm previous findings that flexible stainless steel instruments with noncutting tips exert less canal transportation and more material removal at the inner curvature of curved canals. Thus, instruments with modified tips maintain the original canal curvature better than instruments with conventional tips. Certainly, stainless steel instruments with noncutting tips are an improvement compared to stainless steel instruments with conventional tips (18, 22, 24, 37, 43, 47, 51, 53-55). Nevertheless, up to now even flexible stainless steel instruments with noncutting tips have not produced entirely satisfactory results in terms of adequate centrical enlargement of severely curved canals (22, 47). Titanium-based root canai instruments Besides the described modifications of the geometrical shape of the stainless steel instruments, recently, new alloys characterized by lower E moduli have been developed for root canal instruments in order to overcome undesirable shaping effects especially in severely curved canals. Some of these instruments use titanium, and a distinction has to be made between

nickel-titanium alloys and titanium-aluminium alloys (11,56). Nickel-titanium root canal instruments Recently, several manufacturers have started to produce nickel-titanium (Nitinol^) instruments. These Nitinol hand instruments are being fabricated in a U- and S-shaped configuration and as Kfiles and Hedstrom files. The properties of nickeltitanium make engine-driven instrumentation feasible. In fact, several nickel-titanium instruments are already available for mechanical preparation. These nickel-titanium alloys consist of approx. 55% nickel and 45% titanium by weight (11,57). Owing to their substantially increased flexibility compared with stainless steel instruments, nickel-titanium based instruments are reported to be particularly suitable for preparing cur\/ed root canals. Nickel-titanium instruments are shown to have about three times the elastic

Nickel-titanium is also known as Ni-Ti-NOL (NOL is the abbre\iation for Naval Ordnance Laboratory, Silver Spring, USA, where this alloy has been developed). Nickel-titanium has also been manufactured in China since 1979 as "Nitalloy" (56% nickel and 44% titanium, by weight).

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Schafer

Fig. 2. SEM microphotograph ol different instrument tips (original magnification X160). Left: conventional sharp tip (Flexoreamer, Maillefer). Arrows indicate the regions of the tip which are modified during a special manufacturing process. Right: noncutting so-called Batt-tip (Flexoreamer Batt-tip, Maillefer). Double arrows mark the blunted tip and the guiding collar of the instrument.

flexibility^ in bending and torsion of the stainless steel files (17,'58-61). According to Walia et al. (59) and Tepel et al. (17) nickel-titanium instruments show superior resistance to fracture compared with stainless steel instruments. By contrast, other authors report that flexible stainless steel instruments have greater resistance to fracture than those made of nickel-titanium (60, 62). Both 55- and 60-Nitinol alloys (i. e., alloys containing 55% nickel and 45% titanium by weight or 60% nickel and 40% titanium by weight, respectively) exhibit superelastic behaviour, allowing them to return to their original shape on unloading following deformation (58, 63-65). Alloys that show superelasticity undergo a stress-induced martensitic transformation from a parent structure that is austenite. On release of the stress, the structure reverts back to austenite, recovering its original shape (58). This superelastic behaviour of nickel-titanium occurs over a limited temperature range with an optimum at 37C (63, 66). Moreover, nickel-titanium alloys also exhibit a shape

memory effect. Thus, any deformation of a nickeltitanium instrument can be removed by heating the instrument to a temperature above 125C (58). Concerning the clinical use of nickel-titanium instruments, their superelastic behaviour is very important. As a result of the low modulus of elasticity, nickeltitanium files suffer no permanent deformation when being used in severely curved canals, whereas stainless steel instruments readily undergo permanent deformation. On the other hand, these superelastic properties prevent prebending of the nickel-titanium instruments before their use in curved canals (67), as advocated by several authors (4, 68). Nickel-titanium files are machined rather than twisted. Because of the superelasticity of this alloy it is impossible to twist a nickel-titanium blank counterclockwise in order to produce a spiral, since nickeltitanium alloys undergo almost no permanent deformation. More likely they will fracture when being extensively twisted in order to produce a spiral. It is known that grinding nickel-based alloys is dif-

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Endodontic hand instruments Such structural defects at the cutting edges of nickel-titanium instruments (Fig. 3c) are thought to be responsible for their relatively low cutting efficiency. As Walia et al. (71) and Schafer & Hoppe (56) have pointed out, the cutting efficiency of nickel-titanium K-files is far less compared with flexible stainless steel instruments. Recently, the Maillefer company introduced the Nitiflex-K-file, and the Onyx-R-file was introduced by Union Broach. Concerning cutting efficiency in a rotary motion, these two instruments have proved to be superior to other nickel-titanium instruments, but nevertheless stainless steel instruments obviously are the most efficient instruments. The cutting efficiency in a linear filing motion of nickel-titanium Hedstrom or S-files is only about 40% that of matching stainless steel files (36). Metal flash and surface heterogeneity might allow the nickel-titanium alloy to corrode. Corrosion susceptibility of nickel-titanium under simulated clinical conditions (e.g., temperature, electrolytes of saliva or irrigants) is discussed in the literature with some controversy (58, 12.-^17). Nickel-titanium is reported to exhibit corrosive tendency under the abovementioned conditions (58, 73, 74, 76, 77) whereas, according to other studies, there is no evidence that Nitinol is more subject to corrosion than stainless steel alloys (36, 58, 75). It is reported that some nickeltitanium instruments corrode extremely rapidly under simulated clinical conditions (sterilization procedures and exposure to an endodontic irrigant, i.e., 5% sodium hypochlorite). The instruments show pitting corrosion and separate completely (70). Schafer (11) has conducted an investigation on the effects of different sterilization methods on the cutting efficiency of different root canal instruments. The results demonstrate that one single cycle of steam sterilization or autoclave is enough to produce a significant decrease in the cutting efficiency of nickel-titanium K-files. On the other hand, neither 10 cycles of autoclaving nor steam sterilization cause a reduction in the cutting efficiency of stainless steel instruments. As regards the shaping abilities of nickel-titanium instruments, reports in the literature are contradictor)^ Some authors state that the use of nickel-titanium instruments, as compared with stainless steel instruments, allows for more efficient, faster (78-80) and more centric preparation (81-85) of curved canals. On the basis of research relying on human molars, Haller et al. (84) have found that nickel-titanium instruments prepare curx^ed canals in a manner that is both more centric and more circular than is possible with flexible stainless steel instruments. In contrast to this, other authors state that stainless steel instruments with noncutting tips are superior to nickeltitanium instruments concerning the enlargement of curved canals (71, 86-90). It has been found that nickel-titanium K-files, contrary to stainless steel in-

Fig. 3. SEM microphotograph of different nickel-titanium K-files size 35. Note the structural defects and surface heterogeneity due to manufacturing grinding process (indicated by arrows): a) Mity K-file (JS Dental Mfg, Ridgcfield, CT, USA), b) NiTi K-file (NiTi Corp., Chattanooga, TN, USA) (original magnification X80), c) Hyflex X-file (Hygenic Corp., Mron, OH, USA) (original magnification X160).

ficult, because considerable wear of the milling head occurs within a short time (69). This leads to structural defects especially at the cutting edges of the nickel-titanium instruments (Fig. 3). Some authors have found that the cutting edges of nickel-titanium instruments show irregularities, structural defects or metal flash due to the manufacturing grinding process (56, 58, 59, 70).

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Schafer struments, are unsuitable for enlarging curved canal lumina in accordance with their ISO size, because they wear very rapidly. To achieve the desired canal diameter, it is invariably necessary to use at least two or three instruments of the same ISO size (44, 56). These observations are supported by Gambill et al. (79). They compared the shaping abilities of stainless steel K-files and nickel-titanium instruments and report: "The reason that Ni-Ti instruments caused less transportation than stainless steel K-files when the same filing technique was used may not be due to increased flexibility of the Ni-Ti instruments, but rather to the decreased cutting efficiency of the Ni-Ti instruments" (79). More recently, engine-driven nickel-titanium instruments used in rotary motion were found to produce rounder canals with less transportation than nickel-titanium hand files (82, 84). In summary, the properties of nickel-titanium instruments are discussed with some controversy at present. Further research including the use of enginedriven rotary instrumentation techniques with nickeltitanium instruments is required to evaluate the efficiency of nickel-titanium in root canal instrumentation. Titanium-aluminium root canal instruments Most recently, Microtitane instruments marketed by Micro Mega (Besangon, France) have been introduced. These are titanium-based instruments and consist of about 90% titanium and 5% aluminium, by weight (11, 56). They are available as reamers, Kfiles and Hedstrom files for manual use. As previously described, Microtitane instruments show nearly the same resistance to fracture as flexible stainless steel instruments, but have increased flexibility (17, 91). Unlike nickel-titanium instruments, the Microtitane instruments exhibit no superelastic properties. The cutting efficiency of Microtitane instruments is about the same as that of corresponding conventional stainless steel instruments, but much less than that of flexible stainless steel instruments (11, 36, 56). Moreover, research done by Schafer & Hoppe (56) shows that titanium-aluminium instruments (Microtitane) likewise fail to produce superior preparation results in curved canals, since the amount of material removed on the outer side of the canals is excessive while hardly any material is removed on the inner side of the curvature. Summarizing the present reports in the literature it can be said that flexible stainless steel instruments, especially those with modified noncutting tips, are clearly superior to conventional stainless steel instruments and nickel-titanium or titanium-aluminium instruments with regard to cutting efficiency and instrumentation of curved canals. New geometricai shapes for endodontic instruments Instruments with short cutting segments To enhance instrumentation results in curved canals, instruments with short cutting segments have been developed. Canal Master U (Brasseler USA, Savannah, Georgia, USA) Flexogates (Maillefer) Heliapical (Micro Mega) These instruments incorporate three major features: first, an 0.75 mm to 2 mm noncutting tip, the so-called "pilot", in order to follow the canal curvature without gouging or ledging (92-94); second, a 1 mm to 2 mm (Canal Master U and Flexogate) or 5 mm (Heliapical) cutting segment; and third, a noncutting, parallel shaft, distinctly thinner than the cutting segment (13). It is proposed that owing to the thin nontapered shaft with increased flexibility these instruments will be effective in curved canals by reducing transportation (54, 93, 95, 96). The first instrument with a short cutting segment was the SW^ instrument which was introduced by Wildey & Senia (92) and marketed initially as the Canal Master. The cutting fiutes of these instruments are machined from circular blanks (93). Subsequently, tiying to improve the cutting efficiency of the Canal Master instruments, Brasseler USA have modified the cutting fiutes of the Canal Master and these instruments have been reissued as the Canal Master U because of the U design"^ of their cutting blades (Fig. 4) (97). The Canal Master U instruments are made by grinding a circular tapered blank into a design with "radial planes" (Fig. 4b) and are available in sizes 20 to 80, with a number of half-sizes in between (22.5; 27.5; 32.5; 37.5; etc.) (94). Investigations done by Zuolo et al. (97) have revealed that the Canal Master instruments to a great extent show inconsistencies in the taper and length of the cutting head and are greatly predisposed to wear and breakage. In addition, several authors point out that the Canal Master instruments have a high risk of torsional fracture (93, 98 101). When these instruments separate, it tends to be at a point close behind the cutting head and all fractures are sudden. Saunders & Saunders (49) have investigated the instruments of the second generation, namely the Canal Master U and state that "the Canal Master U had an unacceptably high incidence of fracture". Moreover, Roig-Cayon et al. (94) report that en-

^ The U design goes back to Heath, who in 1988 constructed Ushaped root canal instruments and recommended a rotary reaming motion (4). Subsequently other U-shaped instruments, for example, the Canal Master U as well as the NiTi MAC-file (NiTi Corp., Chattanooga, TN, USA) have been marketed.

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Endodontic hand instruments

Fig. 4. Canal Master U instrument (Brasseler USA, Savannah, CA, USA). These U-files are constructed by grinding three equally spaced grounds. The "radial planes" (marked by arrows) allow for a tolerance in diameters of 0.003 mm (58). a) SEM microphotograph, the cutting fiute of the U-shaped instrument is indicated by an arrow (original magnification X80), b) microscopic presentation of the crosssection of the U-shaped Canal Master U (original magnification X 160).

largement of curved canals with the Canal Master U instruments requires more time and a greater number of instruments than with flexible stainless steel instruments, an obserx'ation also mentioned by Suter (98). Concerning the shaping abilities of instruments with short cutting segments, reports in the literature are inconsistent. Beer (102) states that the Canal Master instruments lead to occasional blocking of curved canals and create rough canal walls. Hankins & FJDeeb (103) have found that the "Canal Master straightened canals significantly more than the step-back technique" using conventional stainless steel K-files. Schafer et al. (104) have also observed that the use of instruments with short cutting segments in curv^ed canals results in severe ledging on the outer side of the curvature whereas almost no material was removed on the inner side of the curvature. Compared with this, other authors report that instrumentation of cur\'ed canals with these instru-

ments results in rounder and better centered preparations with hardly any transportation of the original cui^-ature (54, 92, 94, 95, 97, 99, 105-108). In order to overcome some of the problems described above, the Canal Master U hand instruments are now made of nickel-titanium. Pertot et al. (86) report that the nickel-titanium Canal Master U prepared simulated 35-cur\^ed canals more centrically than the stainless steel Canal Master U. Haller et al. (84) have conducted an investigation using extracted human teeth to study the shaping abilities of the nickel-titanium Canal Master U and stainless steel K-Flex files. Their results demonstrate that, compared with K-Flex files, the nickel-titanium Canal Master U instruments maintain the original curvature better and lead to a more centred instrumentation. Preparation of root canals with these instruments will result in a cylindrical lumen because of their short cutting segment and their nontapered shaft. However, it is accepted that the optimum configur-

59

Schafer ation for prepared root canals is a conical shape. Therefore, the instruments with short cutting segments have to be used in combination with either conventional tapered hand instruments or rotary instruments in order to create a tapered canal (92, 98, 104). Besides the above-mentioned instruments with short cutting segments, the Mani Manufacturing Co. (Tokyo, Japan), have introduced the Apical Reamer with blades extending only 3 mm up the shaft. These instruments are marketed in sizes 20 to 70 (4). As far as I know, no investigations have been published on the characteristics of these instruments. Safety Hedstrom files The Safety Hedstrom file was introduced in endodontics by the Kerr Manufacturing Co. in 1993. The spiral of the working end of the Safety Hedstrom files is characterized by a noncutting side with smoothened edges (safe-side) to prevent ledging in curved canals (Fig. 5). Depending on the direction of the canal curvature, during the enlargement these blunt flutes have to be orientated to the region of the canal wall that requires no more material removal, i.e., where cutting is not desired. It is claimed that the Safety Hedstrom, used in a linear flling motion, will prepare curved canals without ledging or excessive material removal on the outer wall. A flat side on the handle orients the operator to the smoothened edge of the instrument while using it in the root canal. The Safety Hedstrom files are marketed in ISO sizes 5 to 40. Zakariasen & Zakariasen (109) have compared instrumentation of curved canals using the Safety Hedstrom file, and their results indicate that "the Safety Hedstrom file may have some advantages relative to apical transportation" whereas Lin & Glickman (110) report that, irrespective of the orientation of the safeside of the Safety Hedstrom files, transportation of curved canals occurs in all cases investigated. New instrument sizing Instrumentation of severely curv^ed canals and/or partially calcified canals or canals in older patients is time-consuming and often leads to blocking of the root canal. That is why new concepts in instrument sizing have been introduced in endodontics. On the one hand several manufacturers have developed socalled half-sizes and on the other hand Schilder (111) describes a new series of instruments, based on a constant percentage change of instrument dimensions rather than on the variable linear dimensional changes incorporated in the current ISO standard These two aspects will be presented in the following. Half-sizes In the last months, several manufacturers have introduced half-sized instruments, their diameter lying exactly or nearly in between two ISO sizes. So, for example, the Maillefer company produces Flexoreamer and K-Flexofile instruments in half-sizes from 12 to 37. These stainless steel instruments are named "Golden Mediums". Most recently, the VDW company has also started producing conventional stainless steel K-files in sizes 12.5 and 17.5. As already mentioned above, the Canal Master U

Fig. 5. SEM micropiioiograpn ol ihe noncutting side with smoothened edges (safe-side) of a Safety Hedstrom file size 35 (Kerr Co. (original magnification X160).

Endodontic hand instruments instruments have half-sizes in the range from 22.5 to 47.5. Weine et al. (113) and, later, Schilder (16) have recommended the use of incremental instrumentation, especially in narrow sclerotic canals. According to these authors, to reduce undesirable instrumentation effects, intermediate increments should be employed. "This is accomplished by cutting off one millimetre of the tip with sharp scissors and then using a diamond nail-file to re-establish the bevel and the shaip edges from the tip" (36). Obviously, this procedure is very time-consuming and it is quite difficult to produce a noncutting tip with a diamond nail-file. "ProFile Series 29" instruments^ The concept of the ProFile 29 instruments is based on the assumption that the incremental changes at di with instruments manufactured according to the ISO specification are too large, especially at the beginning of the series, i. e., between ISO sizes 10 and 25. For example a size 15 instrument is 50% wider than the size 10 instrument, whereas the percentage difference between an ISO size 60 and size 55 instrument at point di is a mere 9%. Compared with this, the newly designed ProFile 29 instruments show a constant percentage increment of 29.17% at dj between successive instruments. The outcome of this constant percentage change is a parabolic increase in instrument size (35). ProFile 29 instruments are numbered #00, #0 and then #1 to #11. The # 1 instrument corresponds exactly to the ISO size 10 and the #8 corresponds to the ISO size 60. To enlarge a root canal with a diameter of 0.1 mm at the apical constriction up to a diameter of 0.6 mm, 10 instruments rrianufactured according to the current ISO specification are necessary, whereas only 8 instruments constructed according to the new sizing are necessary^ According to Schilder (111) the ProFile Series 29 offers two major advantages compared with the current endodontic armamentarium: first, the instruments are better spaced within the useful range, with more instruments at the beginning of the series and fewer at the end; and second, fewer instruments are necessary to go from the narrowest to the widest instrument size (111). ProFile 29 instruments for hand use are available as stainless steel and nickel-titanium reamers, K-files and Hedstrom files (111) and are marketed by Tulsa Dental Products (Tulsa, Oklahoma, USA). All ProFile Series 29 instruments have noncutting tips (4). So far there appear to be no reports of clinical experience or experimental investigations on these instruments. Outlook Instrumentation of curved canals with flexible stainless steel instruments with modified noncutting tips has been shown to be superior to that possible with any other stainless steel instrument or with nickeltitanium hand instruments. Nevertheless, they do not produce entirely satisfactory results in terms of adequate centrical enlargement of severely curved canals. This problem has resulted in a search for modified instruments and new instrumentation concepts, especially using nickel-titanium alloys. Most recently, reports concerning engine-driven nickel-titanium instruments have been published (114, 115), for example the engine-driven nickel-titanium Lightspeed rotary system, using Canal Master technology. It is operated at rotary speeds of 750 to 2000 rpm (84). In addition, rotary nickel-titanium ProFile 04 instruments (Maillefer) are available. The pronounced taper of 4%, which is twice the taper used in conventional ISO instruments, is claimed to be advantageous in preparing curved canals. Preliminary^ reports on these instrumentation concepts seem to be promising. But undoubtedly, extensive further investigations will be necessary, especially requiring studies on the susceptibility of rotary nickeltitanium instruments to torsional fracture and an evaluation of the clinical efficiency and suitability of these systems. References
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KEREKES K, TRONSTAD L. Long-term results of endodontic treatment performed with a standardized technique. J Endod 1979; 5.'83-90. WEINE FS. Endodo?itic therapy. 4th ed. St. Louis: Mosby, 1989. COHEN S, BURNS RC. Pathways of the pulp. 5th ed. St. Louis: Mosby, 1991. INGLE JI, BAKLAND LK. Eridodontics. 4th ed. Baltimore: Williams & Wilkins, 1994. ST.ADTLER P, JEGLITSCH M . Elastizitat und MaBtreue endodontischer Aufbereitungsinstrumente. Endodontie 1993; 1: 2531. STENMAN E. Effects of sterilization and endodontic medicaments on mechanical properties of root canal instruments. Umea: Odontological Dissertations No. 8, University of Umea, 1977. RtTBiNSTEiN RA. Corrosion phenomenon of endodontic files: a colorimetric analysis. [Master thesis]. Ann Arbor: University'of Michigan, 1973. NEAL RC, CRAIG R G , POWERS JM. Eflect of sterilization and irrigants on the cutting ability of stainless steel files. J Endod 198^3; 5.-93-6. CusTER F, ADDINGTON L. Physical changes of instruments during sterilization. J Periodontol 1965; 36: 348. MORRISON SW, NEWTON C W , BROWN C E . The effects of steam sterilization and usage on cutting efficiency of endodontic instruments. J Endod 1989; 15: 427-31.

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MAO, DUMMER PMH, NEWGOMBE RG. Comparison of six files to prepare simulated root canals. Part 1 and 2. Int Endod J 1992; 25: 57-75. 38. ELDEEB ME, BORAAS JC. The effect of different files on the preparation shape of severely curved canals. Int Endod J 1985; 18: 1-7. 39. ALODEH MHA, DOLLER PM, DUMMER PMH. Shaping of simulated root canals in resin blocks using the step-back technique with K-files manipulated in a simple in/out filing motion. Int Endod J 1989; 22: 107-17. 40. GuLDENER PHA. Endodontie: Wurzelkanalaufbereitung und -fuUung. Schwetz Monatsschr Zahmned 1989; 99: 1019-28. 41. CRAIG RG, MELLWAIN ED, PEYTON FA. Bending and torsion properties of endodontic instruments. Oral Surg Oral Med Oral Pathol 1968; 25.-239-54. 42. DoLAN DW, CRAIG RC. Bending and torsion of endodontic files with rhombus cross-section. J Endod 1982; 8: 260-4. 43. SGHAEER E, TEPEL J, HOPPE W. Rationelles Arbeiten mit Wurzelkanalinstrumenten: Ein Vergleich zwischen herkommlichen und neueren, sogenannten fiexiblen Instrumenten. Osterr Z Stomatol 1994; 91: 161-6. 44. SGHAFER E, TEPEL J, HOPPE W Properties of endodontic hand instruments used in rotary motion. Part 2. Instrumentation of curved canals. J Endod 1995; 21: 493-7. 45. NEWMAN J G , BRANTLEY \VA, GERSTEIN H . A study of the cutting efficiency of seven brands of endodontic files in linear motion. J Endod 1983; 9: 316-22. 46. CAPORALE PF, CIUGGHI B, HOLZ J. Etude comparative au MEB de trois techniques de preparation canalaire a l'aide de
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BRISENO

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Canal Master on root canal preparation: an in vitro study. Int Endod J 1993; 26: 190-7. 106. CAMPS J, MAGOUIN G, PERTOT VVJ. Effects of the Flexogates and Canal Master U on root canal configuration in simulated root canals. Int Endod J 1994; 27: 21^5.
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WiLDEY WL, QuiGLEY NC. Histomorphometric comparison of canals prepared by four techniques. J Endod 1992; 18: 5304. 108. SHANK.\R P, PARAMESWARAN A, LAKSHMINARAYANAN L. Apical third instrumentation of curved canals with K-type and Canal Master instruments. J Endod 1993; 19: 224-7. 109. ZAKARIASEN K L , ZAKARIASEN KA. Comparison of hand, hand/sonic, and hand/mechanical instrumentation methods. J Endod 1994; 2^-205. 110. L I N J , GLICKMAN G N . Comparative evaluation of various ca-

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