1/27/2018 Advances in Biomechanical Preparation | Dentistry Today

Advances in Biomechanical Preparation

Category: Endodontics Created: Tuesday, 28 February 2017 15:51 Written by David A. Beach, DMD, MS Print

INTRODUCTION
During the last few years, endodontics has seen an accelerated advancement in the technology used to clean and
shape canal systems. As with any procedure, equipment and techniques naturally improve in efficiency with
time as new instruments are manufactured that overcome the limitations and weaknesses of those that were
previously available. In terms of endodontic rotary files, the newer generations of files are more flexible and
resistant to cyclic fatigue than ever before.1 In conjunction, as research and understanding of debris removal and
infection in canal systems has improved, the concept of canal irrigation has become more sophisticated.2 Gone
are the days of essentially squirting bleach in a tooth with a conventional needle syringe and gutting roots with
stiff and cumbersome files. Any clinician performing root canal therapy today should be excited by the current
advances in file design and irrigation.

File Design
In 1988, the concept of manufacturing rotary endodontic files from nickel-titanium (NiTi) wire was introduced.3
Since then, the marketplace for NiTi rotary files has exploded with new products being offered by an increasing
number of manufacturers. With nearly 2 and a half decades of rotary files being used in endodontics, much has
changed. Ruddle et al4 classified these files into different generations largely based on file shape, metallurgy,
and motion. The evolution started with first generation rotary files characterized by passive cutting radial lands
and fixed tapers. From there, later generations of files were produced with advanced features such as active
cutting edges, reciprocating motion, and offset centers of rotation. The metallurgy used in NiTi production also
has been advanced, and as Ruddle et al4 discussed, proprietary heat treatments to files has likewise contributed
to an improvement in their strength and flexibility. Regardless of the file system used, the newer generations of
files are more flexible and resistant to separation than at any time in the history of endodontics. The following 2
cases illustrate the safety and efficiency that newer generation files possess.

CASE 1
A 34-year-old male patient presented with a chief complaint of intense pain to temperature stimulation and
chewing in the upper left quadrant. Tooth No. 15 was diagnosed with an irreversible pulpitis with symptomatic
apical periodontitis (Figure 1a). Exceptional root curvature was noted on the preoperative radiograph.

CASE 1

Figure 1. Tooth No. 15 with curves. (a) Preoperative radiograph. (b) Postoperative
radiograph.

http://www.dentistrytoday.com/articles/63-articlesmagazine/Endodontics/10270-advances-in-biomechanical-preparation?tmpl=component&print=1&lay… 1/5
1/27/2018 Advances in Biomechanical Preparation | Dentistry Today

After administering local anesthesia, a rubber dam was placed to isolate the tooth, and access was made. The
ProTaper Gold SX file (Dentsply Sirona) was used to open up the canal orifices and remove the coronal
inflamed pulp tissue. A 10 K-file was used to scout the canals, and working length was determined using the
Root ZX (J. Morita USA). A glide path was created using 10 and 15 K-files, and 6% sodium hypochlorite
(NaOCl) was used to flush debris. Following the establishment of a glide path, the chamber was filled with
NaOCl and the series of ProTaper Gold instruments S1 through F2 (Dentsply Sirona) were used sequentially to
the apex in all canals. Copious irrigation with NaOCl was used after each file before proceeding to the next.
Once instrumentation was completed, the smear layer was removed with 17% EDTA followed by a NaOCl
flush. The canals were dried and sealed with a System B Heat Source downpack (Kerr Endodontics) and Obtura
III Max (Obtura Spartan). The postoperative radiograph shows the ability of one of the most advanced rotary file
systems on the market to shape anatomically narrow and curved canals while minimizing the risk for iatrogenic
accidents (Figure 1b).

CASE 2
A 48-year-old female patient presented with a history of previous root canal therapy on teeth Nos. 14 and 15
(Figure 2a). Tooth No. 14 was symptomatic to chewing and causing spontaneous pain. A periapical radiograph
revealed a large apical lucency on tooth No 14. While the quality of the treatment on tooth No. 15 appeared less
than ideal, the tooth was asymptomatic, and the patient elected to only treat tooth No. 14 to alleviate her
symptoms. The mesial root of No. 14 was noticeably arched, and the possibility of a missed second canal was of
concern.

CASE 2

Figure 2. Upper left quadrant periapical radiograph. (a) Preoperative radiograph.

(b) Postoperative radiograph.

After anesthesia and rubber dam isolation, access was made into tooth No. 14. The ProTaper Gold F1 file was
used along with chloroform to remove the bulk of the gutta-percha from the canals. Small hand K-files were
used with chloroform to remove the remaining gutta-percha at the apices. An untreated second mesiobuccal
(MB) canal was found. The working length was determined using the Root ZX apex locator. The ProTaper Gold
series of files S1 through F3 was used to instrument the canals in the presence of copious 6% NaOCl irrigation.
Stainless steel hand K-files up to size 45 were used to finish the apical preparation of the palatal root. Once
instrumentation was completed, 17% EDTA followed by 6% NaOCl was used to remove the smear layer. With
the canals and chamber filled with NaOCl, the EndoActivator (Dentsply Sirona) was used in each canal to
improve the penetration and disinfecting action of the irrigant. The canals were dried and sealed with a System B
Heat Source downpack and Obtura III Max. The postoperative radiograph shows the treated second MB canal
and presents another example of the ability of today’s more advanced file systems to safely shape curved canals
in anatomically complex teeth (Figure 2b).

Irrigation
Instrumentation alone is not enough to clean a canal system. Irrigation is needed to flush debris from teeth and
http://www.dentistrytoday.com/articles/63-articlesmagazine/Endodontics/10270-advances-in-biomechanical-preparation?tmpl=component&print=1&lay… 2/5
1/27/2018 Advances in Biomechanical Preparation | Dentistry Today

aid in disinfection. Traditionally, endodontics has relied on the delivery of antimicrobial irrigants into the root
canal system by the use of some form of a luer lock syringe and a needle. Canal anatomy is complex, and it is
increasingly apparent that conventional needle irrigation fails to effectively deliver an irrigant into many of the
fins and anastomoses present in teeth.2

Recently, different irrigation techniques and devices have been developed to improve the cleaning of the root
canal system. Ultrasonic or sonic activation, negative pressure irrigation, photon-induced photoacoustic
streaming, lasers, and sound wave-induced hydrodynamic forces have all been promoted within the last few
years to improve the penetration and efficiency of canal irrigation.5 Regardless of the device used, the concept is
the same. Improvement in the removal of debris and bacteria is achieved by actively moving the irrigating
solution in the root canal system. The following 2 cases demonstrate the ability to clean complicated anatomical
canal spaces using an activated irrigation technique.

CASE 3
A 41-year-old female patient presented with pain to chewing associated with tooth No. 19. A periapical
radiograph revealed a large periradicular radiolucency (Figure 3a). Tooth No. 19 was diagnosed as necrotic with
symptomatic apical periodontitis.

Following anesthesia and rubber dam placement, access was made through the existing crown. The ProTaper
Gold SX was used to coronally enlarge the orifices. A 10 K-file was used to scout the canals, and working length
was determined using the Root ZX. A glide path was created using 10 and 15 K-files, and 6% NaOCl was used
to flush debris. Following the establishment of a glide path, the chamber was filled with NaOCl, and the series
of ProTaper Gold instruments S1 through F3 were used sequentially to the apex in all canals. Copious irrigation
with NaOCl was used after each file before proceeding to the next. Once instrumentation was completed, the
smear layer was removed with 17% EDTA followed by a NaOCl flush. With the canals and chamber filled with
NaOCl, the EndoActivator was used in each canal to improve the penetration and disinfecting action of the
irrigant. The canals were dried and sealed with a System B Heat Source downpack and Obtura III Max.

CASE 3

Figure 3. Lower left quadrant periapical radiograph. (a) Preoperative radiograph. (b)
Postoperative radiograph.

Figure 3b shows the complex anatomy that was cleaned and obturated in tooth No. 19. Accessory and lateral
canals in the mesial root became evident after obturation. The bulging area in the mid-portion of the canal in the
distal root, which could not be completely instrumented by files without removing excessive dentin, was cleaned
and well obturated. In areas where files cannot touch, irrigation delivery is the key to success.

CASE 4
An 18-year-old patient presented with a necrotic tooth No. 9 (Figure 4a). The tooth was anesthestized, rubber
dam placed, and access preparation performed. Working length was determined using the Root ZX apex locator.

http://www.dentistrytoday.com/articles/63-articlesmagazine/Endodontics/10270-advances-in-biomechanical-preparation?tmpl=component&print=1&lay… 3/5
1/27/2018 Advances in Biomechanical Preparation | Dentistry Today

The canal was filled with NaOCl, and the series of ProTaper Gold instruments S1 through F3 were used
sequentially to the apex in the canal. Copious irrigation with NaOCl was used after each file before proceeding
to the next. Hand K-files sizes 35 and 40 (Kerr Endodontics) were used to finish apical preparation. Once
instrumentation was completed, the smear layer was removed with 17% EDTA followed by a NaOCl flush. With
the canal filled with NaOCl, the Endoactivator was used to improve the penetration and disinfecting action of
the irrigant. The canal was dried and sealed with a System B Heat Source downpack and Obtura III Max.

CASE 4

Figure 4. Periapical radiograph of tooth No. 9. (a) Preoperative radiograph. (b)

Postoperative radiograph.

The postoperative radiograph in Figure 4b demonstrates how even a seemingly “simple” anterior tooth can
benefit from advanced irrigation techniques. Complex accessory canals visibly appeared after obturation in the
apical area of the root. Smear layer removal and active irrigation contributed to better cleaning and disinfection
in this seemingly straightforward case.

CLOSING COMMENTS
The cases presented here demonstrate the treatment outcomes that are possible with modern endodontic
technology. With all the advances in endodontic instrumentation and techniques that have occurred recently, it
can be overwhelming to keep pace with everything in the marketplace. Clinicians can find themselves lost in a
quandary trying to decide which file system to use. In addition, with the realization that conventional needle
irrigation by itself is not as effective as newer ways to rinse and clean a canal system, one can be left feeling
uncertain of the quality of their patient care. Irrigation is critical to endodontic success and should not be
overlooked.

What works for one clinician may not work well for another. The best advice to find the technique that is right
for you is to attend large dental conventions to get a chance to try some of the latest advances endodontics has to
offer firsthand. The newer files offered are all more flexible and stronger than older generations, so find the one
that is best suited for the types of teeth you choose to treat.

It is an exciting time in the specialty of endodontics, and as amazing as things seem now, one can only wonder
what future advancements are in the works.

http://www.dentistrytoday.com/articles/63-articlesmagazine/Endodontics/10270-advances-in-biomechanical-preparation?tmpl=component&print=1&lay… 4/5
1/27/2018 Advances in Biomechanical Preparation | Dentistry Today

References

1. Hieawy A, Haapasalo M, Zhou H, et al. Phase transformation behavior and resistance to bending and cyclic
fatigue of ProTaper Gold and ProTaper Universal instruments. J Endod. 2015;41:1134-1138.
2. De-Deus G, Barino B, Marins J, et al. Self-adjusting file cleaning-shaping-irrigation system optimizes the
filling of oval-shaped canals with thermoplasticized gutta-percha. J Endod. 2012;38:846-849.
3. Walia HM, Brantley WA, Gerstein H. An initial investigation of the bending and torsional properties of
Nitinol root canal files. J Endod. 1988;14:346-351.
4. Ruddle CJ, Machtou P, West JD. The shaping movement: fifth-generation technology. Dent Today.
2013;32:94-99.
5. Sigurdsson A, Garland RW, Le KT, et al. 12-month healing rates after endodontic therapy using the novel
GentleWave System: a prospective multicenter clinical study. J Endod. 2016;42:1040-1048.

Dr. Beach graduated magna cum laude from the University of Florida College of Dentistry in 2003 and
completed his endodontic residency there in 2005. He is currently a Diplomate of the American Board of
Endodontics and maintains a private practice in Wesley Chapel, Fla. He frequently provides continuing
educational lectures at local, state, and national study clubs and conventions. He can be reached at
drbeachdmdms@verizon.net.

Disclosure: Dr. Beach reports no disclosures.

Related Articles

CBCT Use in Endodontic Diagnosis

Endo Anxiety: Beware the Unwinding of NiTi Files

Root Canals Aren’t What They Used to Be

http://www.dentistrytoday.com/articles/63-articlesmagazine/Endodontics/10270-advances-in-biomechanical-preparation?tmpl=component&print=1&lay… 5/5