JOURNAL CLUB - 8

PRESENT STATUS AND

FUTURE DIRECTIONS:
MANAGEMENT OF
CURVED AND
CALCIFIED ROOT
CANALS
Antonis Chaniotis | Ronald Ordinola-Zapata
 INTRODUCTION
 Hand Instruments ISO standard 3630-153 and the
ADA Standards No. 28 and No. 58 specify general
requirements of root canal instruments for manual
use.

 In general, hand root canal instruments can be

divided into three types:
 Reamers,
 K-files and
 Hedstrom files.

 Today, the majority of hand root canal instruments

are either made of stainless steel or NiTi alloys.
 ENGINE-DRIVEN INSTRUMENTS
AND CURVED CANALS

 STAINLESS STEEL FILES

 NICKEL TITANIUM FILES

CANAL • Torsional stress

CURVATU • Cyclic fatigue
RES
 TORQU
E
Torque is the ability of the hand piece to withstand lateral pressure
on the revolving tool without decreasing its speed or reducing its
cutting efficiency and is dependent upon the type of bearing used
and the amount of energy supplied to the hand piece.

If the torque is set just below the limit

of elasticity for each instrument, the risk
The torque adjustment
of separation is likely to be reduced .
should depend on the
diameters and the
The values are usually low (less than I
length of the file
Ncm) for the smallest and less tapered
engaged as well as the
instruments, but values can be high for
canal anatomy.
the largest and more tapered ones.

Following these concepts. NiTi rotary

instruments should be operated only in
the superelastic field, a range between
the action, which is strongly influenced
by the flute design of the files.
 CYCLIC FATIGUE
 As an instrument is held in a static position and
continues to rotate, one half of the instrument shaft
on the outside of the curve is in tension, whereas
the half of the shaft on the inside of the curve is in
compression.

 According to the studies mentioned previously,

reciprocating motion had better resistance to cyclic
fatigue. (Gambarini et al, Lee et al, Pedulla et al,
Perez-Higueras et al, Rubini et al, Kiefner et al, and
Vadhana et al )
 The cyclic fatigue life of the instruments is influenced
by several factors concerning the geometric
characteristics of the root canals, the physical nature
of the files and the operating modes of the drive motor.
 Indeed, it is known that the failure of the rotary
instrument occurs more rapidly if the canal radius
decreases and the angle of curvature increases .

 Furthermore, some authors demonstrated the position

of the file with respect to the canal to be also a factor
of interest.
 The more the file penetrates inside the canal the more
internal stresses increase, with a consequent decrease
of the working life .
 High taper root canal instruments (larger diameter in
the stem area) are subject to structural failure before
those with smaller diameter .
 TORSION?

Torsion is the axial force of being twisted when one part of a file rotates at a
different rate than another part.

So any distortion of a file that results from twisting – unwinding, is caused by

the stress of torsion.

 A file with a larger diameter can resist more torsion stress than one with a
smaller diameter. The relationship varies very closely with the square of the
file radius.
 So as to say, that a size 0.25 mm diameter can resist as
much as 50% more torque than a size 0.20 mm diameter
having the same design.
 Cause of torsion stress:

• The force of cutting

• The force of screwing-in
• The force of abrasion of the non-cutting
surface
• The force of distortion –from rotating in
curvatures
• The force debris exert on the walls
 NITI ALLOYS
Tapered files that can be
used with rotation or
reciprocation movements
(Baumann, 2004; Walia
et al., 1988).

THE HYBRIDIZATION OF NEW

SYSTEMS
 NICKEL TITANIUM ALLOYS
 Discovered by Buehler in 1962 in the
Space Program of the Naval Ordnance
Laboratory, Maryland
 Introduced into dentistry by Anderson
in 1972
 Consists of approx. 55% wt nickel and
45% wt titanium.
 Properties Of NiTi Unique ability to
negotiate curvatures during continuous
rotation without undergoing the
permanent plastic deformation.
 ADVANTAGES OF NITI OVER STAINLESS STEEL

 Biocompatible

 2-3x more flexible(walia et al 1988)

 Superior resistance to fracture in clockwise and

anticlockwise rotation owing to ductility(walia et al
1988)

 Can retain shape of curved canals and do not

straighten out like ss wire

 Undergo large amount of elastic deformation


DISADVANTAGES OF NITI OVER STAINLESS STEEL

Cutting efficiency of NiTi is only 60% that

of stainless steel file

Low ultimate tensile strength and yield strength than

stainless steel which makes it more susceptible to fracture.

Does not give any signs of wear before it fractures

METALLURGY
SUPER
 SHAPE
MEMORY
 200
ENGINE-DRIVEN INSTRUMENTS
DESIGN
 The following considerations are
important in formulating techniques to
approach difficult cases (McSpadden,
2007):
1 •A file - more efficient cutting design requires less torque, pressure, or time to accomplish root canal enlargement.

2 •In a straight canal, withstand torsion is related to the square of its diameter.

3 •In a curved canal, resist fatigue has an inverse relationship with the square of its diameter.
 4

FATIGUE
INCREASES WITH THE

Number of rotations of the file in a

curvature
5

The degree of curvature of the canal.

 • The torque - varies directly
6 with the surface area of the
file's engagement in the canal.

• To improve efficiency, the

smaller the surface area of a
7 file engaged in the canal, the
greater the rotation speed
should be.
• The more spirals a flute has
per unit length around the
shaft of a ground file, the less
8
resistance to torsion
deformation there is, but the
more flexible the file is.

• The sharper the cutting blade

9 of a file, the fewer spirals per
 • The greater the number of
flutes with similar helix angles,
10 the greater the tendency of the
file to screw into the canal and
become bound.

• Maximum engagement of a file

occurs when it progresses into
the canal at a rate that is equal
11 to its feed rate, the rate the file
progresses into the canal
without the application of
positive or negative pressure.

• Less canal transportation

occurs with a file having
6 greater flexibility, an
asymmetrical cross section
design, and/or a land.
 METALLURGY
C
T
h
h
e
e
 NITI alloys - The mechanical properties vary
m
r
ic
m
al
al
c
tr
o
e
m
a
p
t
o
 Heat treatments
m
si consist of controlled
e
ti
heating and cooling undern controlled
o
conditions to obtain specific
t properties that
n
will improve clinical behaviour (Shen et al.,
2011).
 CHRONOLOGICAL ORDER (GAVINI ET AL., 2018)

 ELECTROPOLISHING (ELECTROCHEMICAL
SURFACE TREATMENT; 1999):
Surface treatment - Manufacturing
defects to
the cutting efficiency and fatigue
resistance of the file (Gavini et al.,
2018; Anderson et al., 2007).
Engine-driven
instruments of
different heat
treatments.
 M-WIRE (2007): Unique thermomechanical
procedure at various temperatures, applied
before the machining of a new Niti alloy
composed of 55.8% Ni.
MARTENSIT
R PHASES
IC

 Higher cyclic fatigue resistance and

enhanced mechanical properties compared
to conventional superelastic NiTi files
Gambarini et al., 2008, 2011; Gavini et al., 2018
 R-PHASE (2008): Additional R-phase change in the
crystal structure of the alloy.

 This allows twisting of the wire rod to create the flutes by

plastic deformation and heat treating it to recrystallization.

 improves flexibility and strength.

 An additional special oxidation bath surface treatment

increases the hardness of the file without changing its
flexibility.

 This twisting process ensures greater resistance than

grinded instruments.
Gambarini et al., 2010; Gavini et al., 2018
 CM WIRE (2010):

Hyflex CM, Thypoon Infinite

Flex NiTi Files, V-Taper 2H,
and Hyflex electrical
discharge machining (EDM).

Gambarini et al., 2010; Gavini et al., 2018

 CM BLUEWIRE & CM GOLDWIRE (2012 & 2014):

 NiTi CM alloys treated continously and

cooled

SURFACE COLOUR

Thickness of the layer of

titanium oxide

 In the NiTi Blue Wire alloy - 60–80 nm,

 The NiTi Gold alloy, this thickness is 100– 140 nm.

 The rigid titanium oxide layer compensates for the loss of

hardness enhancing cutting efficiency and wear resistance
PLOTINO ET AL., 2014; GAVINI ET AL., 2018
 Max Wire (2015):

 >35°C – M A phase

 Semi-Circular shape - project against the

walls of the root canal when rotating,
XP-ENDOSHAPER
 ECCENTRIC ROTARY MOTION

 Supplementary cleaning of the canal at the end of

chemical and mechanical preparation
Bao et al., 2017; Gavini., 2018
ENGINE-DRIVEN INSTRUMENTATION TECHNIQUES

General engine-driven technique

considerations

 McSpadden (2007) suggested nine considerations for

the safer engine-driven instrumentation of curved
canals with superelastic NiTi files (McSpadden,
2007):
 The tip design that
Advance a file into
will not burnish or
the canalthe
transport with no
canal
more than 1
(non-cutting mm
guiding
increments
tips) with
To advance a
insert/withdraw
particular file the
motions
first 1 mm (usually
into a
three
canalpecking
after it
movements
becomes engaged,and a
File advancement
remove
minimal to clean
specific
into the cana lshould
flutes and canal).
pressure
be able toneeds occurtoatbe a
applied
rate of (feed
at least rate½of
>0.02 taper, do not
themm file).
per the applied
second
advance more than
without stresses.
increasing
2Except
mm beyond for 0.02 the
the pressure
preparation of for
the
tapered files having
insertions
previous file if any
a size diameter of
part
0.20 ofmmthe andfile is
engaged
smaller, doinnota
engage curvature.
more than
6 mm of the file's
 whilst advancing
into the canal and
try to avoid
negative (screw in)
forcesthe
Beyond around
point of
curvatures
curvatureby in using
the
smaller
apical zone, the files
tapered file
and files
diameter of be
should
asymmetrical
no greater thancross
0.60 mmsection.
for a 0.02
taper,
0.55 mm for 0.04
When any of the
taper,
parameters
0.50 mm for 0.06
cannot
taper,be met,
and
changing
0.35 mm forto aa0.08
file
havingtaper.
a different
taper in the
technique
sequence will
 SPECIALIZED ENGINE-DRIVEN TECHNIQUE
CONSIDERATIONS

 The zone technique The smaller diameter

 McSpadden (2007) tip of a file can
negotiate an apical
 variations in the pressurecurvature easier than
 Force the larger diameter
 Apical/midroot portion can negotiate
the same amount of
diameter should be no curvature in the
greater than 0.60 mm for coronal or mid-root
a 0.02 taper, part of the canal
0.55 mm for a 0.04 taper, (McSpadden, 2007).
0.50 mm for a 0.06 taper
and 0.35 mm for a 0.08
taper (McSpadden, 2007).
Graphic representation of the Zone technique (Coronal
zone, apical zone and protocol diameters are
represented) (McSpadden 2007),
 2 objectives in mind to minimize file
stress for any type of NiTi rotary file
used for the preparation of curved
canals.
 The canal diameter coronal to the
curvature should be large enough to
prevent any engagement in that portion of
the canal when any file is being used
apical to the curvature, and
 The file diameter is not too large to rotate
safely in a curvature.
A. STEP ONE
 Dividing the canal into zones according to
the location of the curvatures or
constrictions in relation to the apex can
simplify canal preparation with each zone
having a different technique.

 The tactile feedback during file insertion.

 1 mm increments, is exceeded
A. STEP TWO
 Determine the distance each of the files having
different sizeslimitations
Diameter and tapersin can safely
canals be advanced
having
around curvatures.
different curvatures can be extrapolated
mathematically.
 Two factors
By using are to be
the diameter considered,
limitations for athe WL
curvature of
45° and
and the
8 mm radius
radii,ofthe
curvature.
following formula is
If the radius is 16 mm (two times the
suggested:
amount
Length stated
that the in be
file can theprojected
parameters),
around the
the curvature
diameter
= diameter limitation of
limitation−file tip asize
06 taper file is
larger thanfile 50taper
based on the square of the
file diameter.
For cases with an apical zone greater than
6 mm, curvature more than 45° and radius
less than 8 mm, the diameter limitations
Graphic representation of the single file reciprocating
technique (3 pecks of 1 mm amplitude guide the
reciprocating file to length after 3 insertions)
(Yared 2008)
 If more flexible and fatigue-resistant martensitic heat
treated rotary NiTi files are to be used with the zone
technique, the suggested diameter limitations will have
to be re-adjusted to larger sizes for the same parameters
of curvature.

 This adjustment will result in the ability to deliver larger

apical preparations during the enlargement of curved root
canals.

 The enlargement technique also will have to be re-

adjusted to accommodate larger preparations with heat-
treated files
RECIPROCATING TECHNIQUE
 Single file reciprocating instruments - with a single
instrument.

 Can be obtained without prior glide path preparation.

 The reciprocating movement

 The instruments cut dentine in a counterclockwise (CCW)

direction and are released in a clockwise (CW) motion.

CW rotation is smaller than the CCW rotation

The releasing motion removes the stress from the
instrument and prevents instrument fracture.

Plotino et al., 2015

 The ability of the reciprocation technique to
achieve the WL in straight canals without glide
path is 96.4%, and for moderately curved
canals is 90.7% (De-Deus et al., 2013).

 The movement suggested with the

reciprocating files is 3 pecking insertions with
less than 1 mm amplitude.

 Straight stainless steel size 0.8 K-file

 Maxillary second molar in a young adult with symptomatic
irreversible pulpitis and normal apical tissues. Note the difficulty
to assess the root canal anatomy due to the superimposition of
the maxillary third molar in the periapical image (a). A limited
field of view CBCT revealed the presence of a multiplanar
curvature in the mesiobuccal root, proximity of the maxillary
sinus and normal apical tissues (b). Glidepath was obtained using
hand files (c), the instrumentation was accomplished by using .04
NiTi instruments (d). The result showed adequate preservation of
TACTILE CONTROLLED ACTIVATION (TCA)
TECHNIQUE

 The complexity of root canal systems

and the need to minimize file
engagement and torsional loading
during instrumentation of dilacerated
canals - a novel approach - Chaniotis &
Filippatos, 2017.
The TCA technique can be defined as the
single stroke activation of a motionless
(stationary) engine-driven file only after it
becomes fully engaged inside a patent canal
and tactile feedback of the underlying
anatomy is gained.
 Graphic representation of the stationary, in-stroke and out-
stroke steps of the single stroke Tactile Controlled Activation
(TCA) technique
(Chaniotis & Filippatos 2017)
 File activation only after maximum engagement
of the file below the fulcrum of the curvature is
achieved and tactile feedback of the anatomy
and topography of the curve is gained.

 By inserting non-rotating files with smaller

diameters around curvatures and withdrawing
with rotation, the severity of the curvature can
be easily determined whilst avoiding excessive
stress (McSpadden, 2007).
 It can be divided into three phases:

Torsional failure

CROWN-DOWN APPROACH
THE FLEXIBLE MARTENSITIC
INSTRUMENTS – free from
 Highly curved maxillary molar managed with Tactile Controlled
Activation (TCA) instrumentation technique a. Preoperative
radiograph, b. 15/04 CM file stationary insert, c. TCA radiograph, d.
Straight view postoperative radiograph revealing the curvature
parameters in mesio-distal plane (25/.04 mm per mm tapered
preparation in the buccal roots), e. Proximal view postoperative
 A mandibular second molar with asymptomatic irreversible
pulpitis and normal apical tissues presenting 2 mesial roots (a).
An “S” shaped curvature is present in the MB canal (b), the root
can be described as long and thin. The TCA technique was used
to achieve a 25/.04 mm per mm tapered preparation (c-f).
ARITHMETIC CROWN-DOWN DYNAMIC TACTILE
INSTRUMENTATION TECHNIQUE.

 Elkholy & Ha (2021)

 Combination
 The technique is divided into the
following steps:
 Step 1: Determination of zones
 Step 2: Coronal zone flaring

equation:

The depth of insertion of the coronal

flaring instrument can be determined by
the following equation:
Lcurrent = Lfinal − f
 Step 3: Canal negotiation, WL, glide path and
confirming curvature analysis (securing the
glide path)
 08 K-file

 Step 4: Apical advancement

 Aftersecuring the glide path and confirming the
boundaries of the first canal curvature the size 25, 0.06
taper flaring file can be inserted to the 17.5 mm from the
reference point boundary as calculated by the equations.
 Since this depth of insertion is beyond the boundary of
the first curvature, a TCA needs to be applied.
 The file is inserted passively into the canal until
engagement of the walls is tactilely felt and then
activated to resistance with activation and redrew from
the canal without exceeding the 17.5 mm boundary
 Step 5: Apical zone finishing
 Precurved martensitic files are inserted into
the canal pointing towards the curvature,
 engaging the walls of the canal and
 activated until reaching the WL with three
gentle apical strokes instead of one at a time
as described in the original TCA technique.

In more challenging
anatomies,smaller size martensitic
files might be needed to reach the
WL
optimum canal engagement
for cutting and avoids
unnecessary stresses
 DISINFECTION-RELATED FACTORS
 The ability of an irrigant solution to be
distributed in the apical third depends
upon the following factors:
 The irrigation delivery technique
 The level of the needle penetration
 The type and gauge of the needle
 The canal anatomy
 The final size and taper of root canal
preparation
 The irrigant activation techniques used
 Finer and more flexible irrigation needles (31–32 G)
may reach closer the apical third in such cases;
however, small needles require three to six times
stronger force to be applied to the syringe compared
to a 30 G needle, to obtain the same flow rate
(Boutsioukis et al., 2007).

 It is also unlikely that sonic or ultrasonic activation

can provide clinical advantages in extremely curved
canals. Multi-point wall contacts inside constricted
canals will probably dampen the oscillation of the
activation instrument more than in straight canals
(Walmsley & Williams, 1989).
 Evidence- the main alternatives for irrigant
activation in narrow and curved canals are
manual dynamic activation using gutta-
percha points (Huang et al., 2008) or a
multisonic activation system (Molina et al.,
2015; Wang et al., 2018).

 Increasing the temperature of sodium

hypochlorite might decrease its viscosity and
improve the flow and effectiveness of the
irrigant in curved and narrow canals (Zehnder,
2006).
Recently, machine-assisted
irrigation, such as PIPS
(Fotona LLC) and the
multisonic GentleWave (GW)
system(SonendoInc,LagunaHil
ls,Ca,USA),have been
introduced to improve the
cleaning of minimally
instrumented canals or even
Recently, acanals
uninstrumented new method was reported
for treatment
(Haapasalo of calcified teeth called
et al., 2014).
‘Guided Endodontics’ (Krastl et al.,
2016; Zehnder et al., 2016).
Computer-aided surgical navigation
technology has also been incorporated
At present, a new software program, 3D
Endo (Dentsply Sirona), - with the CBCT
data sets to evaluate root canals including
curvatures.
The clinician to visualize the root canal
anatomy, assess the initial canal
diameters and determine working lenght
measurements
-Patel, Brown, et al., 2019a; Patel, Patel, et al., 2019b.
 CONCLUSION
 A consistent strategy is based on the following
principles:
 Diagnosis of the apical pathosis,
 Preoperative radiographic interpretation of the pulp
chamber and canal anatomy,
 Customized design of the access cavity to fit the
underlying anatomy,
 Exploration of the pulp chamber under magnification
and coaxial illumination,
 Use of ultrasonics and long-shafted burs to locate and
penetrate calcifications,
 Securing and maintaining a reproducible glide path, and
 safe enlargement of the calcified and curved canals
with highly flexible and fatigue-resistant instruments.