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Int Endodontic J - 2022 - Chaniotis - Present Status and Future Directions Management of Curved and Calcified Root Canals
Int Endodontic J - 2022 - Chaniotis - Present Status and Future Directions Management of Curved and Calcified Root Canals
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Received: 12 November 2021 Accepted: 18 January 2022
DOI: 10.1111/iej.13685
REVIEW ARTICLE
Antonis Chaniotis1 | Ronald Ordinola-Zapata2
1
Private Practice, Dental School, Abstract
National and Kapodistrian University
Root canal curvature and calcification introduce factors that increase the risk of pro-
of Athens, Athens, Greece
2
Division of Endodontics, School of
cedural accidents during root canal treatment. The inability to achieve patency to the
Dentistry, University of Minnesota, apical third, asymmetrical dentine removal leading to transportation, perforation,
Minneapolis, Minnesota, USA and instrument fracture inside the curved trajectories are some of the procedural
Correspondence problems that might jeopardize the management of intraradicular infection and re-
Antonis Chaniotis, Private Practice sult in poor treatment outcomes. In fact, curved and constricted canals introduce
–microEndodontics, 140 El. Venizelou
such complexity that total instrumentation concepts and specially designed instru-
Av., Stoa Karantinou, 1st floor, 176 76
Kallithea, Greece. ments have been developed to deal with the challenge. This narrative review seeks
Emails: [email protected], to provide and consolidate the principles necessary for understanding the dynamics
[email protected], [email protected]
of curved and constricted canal management and to improve the understanding for
future developments in this field.
KEYWORDS
engine-driven instruments, instrumentation techniques, manual instruments, root canal anatomy,
root canal curvature
I N T RO DU CT ION shaping of the root canal system. The main goals are
(Hülsmann et al., 2005):
Root canal treatment encompasses procedures that are
designed to maintain or restore the health of the peri- 1. The access to the pulp cavity and the radicular space.
radicular tissues (European Society of Endodontology, 2. The removal of infected vital or necrotic tissues from
2006). To remove bacteria and their by-products, the root the main and lateral extensions of the root canal system.
canal needs to be debrided following specific mechanical 3. The creation of adequate space for effective disinfec-
goals. Instrumentation of the root canal system has been tion and medication.
recognized as one of the most important tasks that can 4. The preservation of the original anatomy avoiding iat-
impact the subsequent stages of treatment. From the bi- rogenic alterations.
ological point of view, this procedure aims to provide an 5. Respect to the periapical tissues.
environment that favours healing of periapical tissues 6. The creation of a shape that allows the obturation with
and at the same time promote the filling of the root canal current filling methods.
system (McSpadden, 2007). This procedure begins at the 7. The preservation of tooth structure by removing the
level of the crown with the access cavity preparation and less possible amount of dentine structure that is neces-
progresses towards the apical terminus with the adequate sary to achieve effective disinfection.
© 2022 International Endodontic Journal. Published by John Wiley & Sons Ltd
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656 wileyonlinelibrary.com/journal/iej Int Endod J. 2022;55(Suppl. 3):656–684.
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CHANIOTIS and ORDINOLA ZAPATA 657
T A B L E 1 Root canal treatment difficulty assessment according to the degree of root canal curvature (American Association of Endodontists, 2010; Canadian Academy of Endodontics,
curved canals. Constricted canals and curvatures intro-
Exceptional curvature
duce factors that can increase the risk of procedural er-
>60° or S-shaped
rors during root canal preparation. These errors include
transportation, ledges, perforations, instrument sepa-
ration, asymmetrical dentine removal, and alterations
>60°
of the internal anatomy (Roane et al., 1985; Schäfer &
Dammaschke, 2006). Although these errors are not the
direct cause of treatment failure, they decrease the prog-
nosis, because procedural errors decrease the ability
of clinicians to eliminate the intracanal infection (Lin
Note: Curvatures of more than 30° Schneider angle are considered of high difficulty and risk for procedural accidents in most difficulty level assessment forms.
Extreme curvature (+30°)
et al., 1982; Mullaney, 1979; Roane et al., 1985; Weine
et al., 1975).
Severe curvature
Severe curvature
The presence of root canal curvatures and calcifica-
High difficulty
Very high risk
Curvature >40°
Complexity 3
tions has been listed by several authors as a risk factor that
may affect the outcome of root canal treatment (American
30°–60°
45°–60°
Association of Endodontists, 2010; Canadian Academy of
Moderate curvature
Moderate curvature
Moderate curvature
specialized management. The various classifications of
Curvature 15°–40°
difficulty assessment tools in relation to root canal curva-
Complexity 2
(10°–30°)
(10°–30°)
Although these case assessment tools provide an initial
15°–30°
Score B
framework to differentiate between high and low difficulty
curved canals, they do not include detailed guidelines on
2017; Essam et al., 2021; Falcon et al., 2001; Ree et al., 2003; Shah & Chong, 2018)
Small or no curvature
Minimal difficulty
Complexity 1
<15°
T H E P RO B L EM OF CU RVE D
A ND CO N ST RICT E D CANAL
I N ST RUM E NTAT ION
(2017)
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658 CURVED AND CALCIFIED ROOT CANAL MANAGEMENT
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CHANIOTIS and ORDINOLA ZAPATA 659
length and working width of each root canal (Jou et al., outcomes. Gorni and Gagliani (2004) reported that the
2004). The working width addresses the horizontal dimen- success of retreatment procedures when the apical anat-
sions of a root canal, and was described by the diameter omy was addressed was almost twice compared to teeth
of the canal that corresponded to the tip size of the final in which the root canal anatomy was altered (86 vs.
hand instrument used up to WL (Jou et al., 2004). Micro- 47%). In a review, the impact of modern nickel-titanium
computed tomography research has provided an extensive instrumentation on clinical outcomes revealed interest-
understanding of the anatomy of the root canal system ing results (Schäfer & Bürklein, 2012). Evidence from
and morphometric parameters including apical diameter, one clinical study suggested that improve maintenance
roundness and geometry of the canals along their length. of the anatomical canal curvature and shape resulted in
In the clinical scenario, cone beam computed tomography increased success rates (Pettiette et al., 2001). Evidence
(CBCT) has also the ability to delineate the canal diameter from another clinical study indicated that ledging of
along the length of the tooth (Patel, Brown, et al., 2019a; root canals result in poor success rates (Cheung & Liu,
Patel, Patel, et al., 2019b). 2009). Although these studies revealed that the use of
Wider apical preparations of up to six to eight sizes nickel-titanium instruments significantly improved the
larger than the first binding file at the apex have been pro- outcome of nonsurgical root canal treatment compared
posed to allow for adequate instrumentation of the apical to the use of hand instruments, three studies failed to
third (Weiger et al., 2006). However, increased apical in- reveal any meaningful differences (Fleming et al., 2010;
strumentation of curved canals was associated to incom- Iqbal et al., 2009; Marending et al., 2005).
plete apical preparation and unnecessary dentine removal Even though instrumentation-induced alterations of
(Elayouti et al., 2011). Moreover, there is no anatomical ev- the internal anatomy of curved canals, they are not the
idence that the first binding endodontic instrument reflects direct cause of treatment failure. Procedural accidents in-
the diameter of the canal at its terminus (Jou et al., 2004). crease the risk of failure because a necrotic canal space
A recent systematic review addressed the issue with apical transportation decreases the probability of
of whether the size of apical instrumentation affects eliminating intraradicular infection (Lin et al., 2005).
healing in patients undergoing root canal treatment
(Aminoshariae & Kulild, 2015). The results of this review
confirmed that only one randomized-controlled trial was ANATOMY OF THE PULP
available. In addition, there were no longitudinal evalua- C HAMBER AND CORONAL ACC E S S
tions using three-dimensional imaging. It was concluded TO THE CALC IFIED C ANAL
that nowadays the best available evidence suggests that SYSTEM
for patients with necrotic pulps and apical periodontitis,
greater enlargement of the apical third would result in an The management of calcified and curved canals begins
increased healing in terms of radiographic and clinical with the pulp chamber access. The pulp chamber is in the
outcomes (Aminoshariae & Kulild, 2015). In a more re- centre of the anatomical crown, and its internal anatomy
cent prospective randomized clinical trial (Fatima et al., resembles the shape of the occlusal surface. Occasionally,
2021), evaluated the effect of apical preparation size and discrete or diffuse calcifications can alter the pulp cham-
taper on postoperative pain and healing after primary ber size. Discrete calcifications may appear as nodules or
root canal treatment. Although no difference in postop- pulp stones. Pulp stones occur most frequently in the cor-
erative pain was found, apical enlargement to two sizes onal pulp. Based on location, pulp stones can be embed-
larger than the initial apical binding file with 4% taper ded, adherent, and free (Goga et al., 2008). Adherent and
was judged insufficient and resulted in lower success rates embedded pulp stones can restrict instrumentation if they
compared to larger preparations when two-dimensional cause blockage of canal orifices or are located at the curva-
images were used to assess healing. ture level. Diffuse calcifications can generally be observed
in root canals of older adults, but they may also be present
in the pulp chamber of younger patients affected by caries.
T H E E F F ECT OF CANAL Severely calcified teeth are predisposed to tooth perforation
C URVAT U RE IN ROOT CANAL during pulp chamber access or the initial location of the
T R E AT M E NT OU TCOM E canal orifice. Attached stones prevent the easy passage of
explorers or other endodontic instruments down the canal.
Root canal curvature is the main intraoperative risk Normally, the calcification process progresses in a corono-
factor linked to transportation, asymmetrical den- apical direction, so once the initial canal has been captured,
tine removal and instrument separation. Altered root an instrument tends to progress easily as it advances to-
canal morphology has been linked to poor treatment wards the canal terminus (McCabe & Dummer, 2012).
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660 CURVED AND CALCIFIED ROOT CANAL MANAGEMENT
To negotiate calcified canals, the anatomy of the pulp drawn in a mesial-distal direction across the centre of
chamber must be revealed (Figure 2). Based on the ana- the floor of the pulp chamber.
tomical study of 500 teeth, several laws for aiding the de- • Law of colour change: The colour of the pulp chamber
termination of the pulp chamber position as well as the floor is always darker than the walls.
location and number of root canal orifices in each group • Law of orifice location 1: The orifices of the root canals
of teeth have been proposed (Krasner & Rankow, 2004): are always located at the junction of the walls and the
floor.
• Law of centrality: The floor of the pulp chamber is al- • Law of orifice location 2: The orifices of the root canals
ways located in the centre of the tooth at the level of the are located at the angles in the floor-wall junction.
cemento-enamel junction (CEJ). • Law of orifice location 3: The orifices of the root canals
• Law of concentricity: The walls of the pulp chamber are are located at the terminus of the root developmental
always concentric to the external surface of the tooth fusion lines.
at the level of the CEJ, that is, the external root surface
anatomy reflects the internal pulp chamber anatomy. To take full benefit from these laws, the use of micro-
• Law of the CEJ: The distance from the external surface scopic magnification and coaxial illumination is indispens-
of the clinical crown to the wall of the pulp chamber is able. Microscopic exploration through an access cavity
the same throughout the circumference of the tooth at can reveal all anatomical variations and limitis of the pulp
the level of the CEJ. chamber resulting in the identification of all canal orifices,
• Law of symmetry 1: Except for maxillary molars, the ori- their topography, and angle of entry. The specific equip-
fices of the canals are equidistant from a line drawn in a ment required includes long-shafted miniaturized burs,
mesial-distal direction, through the pulp chamber floor. thin endodontic explorers, highly reflective mirrors, file
• Law of symmetry 2: Except for the maxillary molars, the holders, ultrasonic tips, and diagnostic dyes (Figure 3).
orifices of the canals lie on a line perpendicular to a line Usually, the first penetration to the pulp chamber is done
(a) (b)
F I G U R E 2 Mandibular first molar in an elderly patient. (a) The radiographic image shows the presence of an indirect restoration, a
calcified pulp chamber (arrow) and periapical pathosis in the mesial and distal roots. This calcified molar was successfully managed (b) by
using Krasner and Rankow principles (c–e). The access is in the centre of the crown (c). The pulp exposure is observed under magnification
(d). Canal orifices were found with ultrasonic tips and a sharp endodontic explorer at the junction of the chamber walls and the pulpal floor
(e).
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CHANIOTIS and ORDINOLA ZAPATA 661
with a rounded end tapered diamond bur. Once inside the follows. The factors that have been observed to exert an
chamber, non-cutting carbide multiblade burs can be used impact on the ability to deliver anatomically guided prep-
for the safe enlargement and refinement of the access cav- arations in curved and calcified root canals can be clas-
ity. For a deeper search of canal orifices through the pulp sified into anatomical factors, instrument-related factors,
chamber floor, longer burs of small diameters may be bene- and disinfection-related factors.
ficial, such as the conical Endo-Guide (SSWhite, Lakewood,
NJ, USA) micro-access fissure burs (Figure 3b) or a round-
end low-speed Munce discovery burs (CJM Engineering, ANATOMY- R ELATED FACTORS
Inc. CA, USA; Figure 3c). These burs are useful to clean
pulp horns and allow for selective dentine removal. They Most human root canals are curved to one or multiple
also provide a visual microscopic corridor that permits di- planes and multiple degrees; suggesting that a tooth with
rectional control under the microscope. Furthermore, thin a straight root canal and a single foramen is the excep-
explorers are useful in the location and determination of tion rather than the rule (Vertucci 2005). Initial attempts
the direction of the root canals (DG-16 and JW-17). to describe and classify root canal curvatures (Nagy et al.,
The Munce discovery burs are useful when it is neces- 1995) suggested four categories: straight or I form (28% of
sary to discover canals deep inside the root (Chaniotis & the root canals), apically curved or J form (23% of the root
Plotino, 2021). Rhodium surface mirrors allow for great canals), entirely curved or C form (33% of the root canals)
visibility and light transmission, especially through small and multicurved or S form canals (16% of the root canals;
access cavities or indirect restorations avoiding double Nagy et al., 1995). Additional radiographic assessment of
image and refraction. Handle files attached to a handle the frequency and degree of canal curvatures revealed that
or mounted in a file holder are extremely helpful in ne- 84% of root canals are curved at least in one direction and
gotiating calcified canals under the microscope. The use that 17.5% of all curved canals exhibited a secondary cur-
of ultrasonic diamond tips for access cavity refinement or vature to a different plane and are classified as s-shaped
orifice location allow to remove dentine structure in the (Schäfer et al., 2002). In another radiographic study, all
proximities of the pulpal floor with great visibility (Figure canals in mesial roots of mandibular molars were found to
3a). Ultrasonic tips are also useful to remove calcifications be curved in the clinical view, whilst 30% of the curved ca-
in the pulp chamber without damaging the access walls nals exhibited a secondary curvature in the proximal view
or the pulp chamber floor. Furthermore, when ultrasonic (Cunningham & Senia, 1992).
tips are used under the microscope to locate root canal ori- The most widely used method of measuring the root
fices, the accessory anatomy can be revealed with minimal canal curvature magnitude is by using the Schneider
dentine removal (Chaniotis & Plotino, 2021). angle of curvature (Schneider, 1971). According to this
classification, root canals presenting an angle of 5° or less
could be classified as straight canals, canals presenting an
RADI C UL A R ACCE SS AN D CANAL angle between 10° and 20° as moderate, and root canals
E N L A RG E M EN T presenting a curve greater than 25° as severely curved ca-
nals (Schneider, 1971). Severely curved canals are also fre-
After coronal access and canal identification, the radicu- quently referred in the literature as dilacerated. The term
lar access and the anatomical root canal preparations dilaceration is defined as a deviation or bend in the linear
(a) (b)
(c) (d)
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662 CURVED AND CALCIFIED ROOT CANAL MANAGEMENT
T A B L E 2 Prevalence of root dilacerations amongst tooth types % (Bodrumlu et al., 2012; Hamasha et al., 2002; Kuzekanani & Sadeghi,
2019; Ledesma-Montes et al., 2019; Malcic et al., 2006; Miloglu et al., 2010; Nabavizadeh et al., 2013; Udoye & Jafarzadeh, 2009)
Tooth type
Prevalence Prevalence
(Periapical) Frequency (Panorax) (Periapical) Prevalence (Panorax)
Maxillary 54.4
Central Incisor 0.4 0.8 1.2 0.53
Lateral Incisor 1.2 13.6 7.0 1.43
Canine 0 2,4 3.6 0.74
First Premolar 3.2 12 4.5 3.32
Second Premolar 4.7 13.6 6.7 4.10
First Molar 3.4 6.4 15 7.01
Second Molar 3.4 4.8 11.4 7.84
Third Molar 1.3 8.1 8.46
Mandibular 45.6
Central Incisor 0.5 0 1.7 0.42
Lateral Incisor 0 2.4 0 0.32
Canine 0.5 7.2 1.2 0.93
First Premolar 3.3 9.6 2.1 1.42
Second Premolar 2.8 6.4 1.5 1.99
First Molar 5.6 7.2 2.2 0.45
Second Molar 3.6 12 1.7 1.99
Third Molar 19.2 24.1 30.92
Total 3.8 1.6
Note: Higher prevalence is highlighted with red colour, followed by orange and green. Most studies agree that the prevalence of dilacerations is higher
in mandibular third molars, followed by maxillary lateral incisors and maxillary premolars.
relationship of a crown of a tooth to its root (Jafarzadeh & et al., 1997) and is defined as the radius of a circle passing
Abbott, 2007). The criteria for describing root dilaceration through the curved part of the canal. Thus, two canals can
vary amongst different authors. According to Hamasha present the same angle of curvature, but different abrupt-
et al. (2002), and Malcic et al. (2006), a tooth is considered ness of curvature (Pruett et al., 1997). The instrumenta-
to have a dilaceration if there is at least a 90° angle along tion difficulties for a curved canal trajectory significantly
the axis of the root, whereas others defined dilaceration will increase as the angle of curvature increases and the
as a deviation from the normal axis of the tooth of 20° or radius of curvature decreases (Al-Sudani et al., 2012).
more in the apical third of the root (Chohayeb, 1983). The The location of the curvature has been reported to
prevalence of dilacerated roots amongst different tooth have a much greater impact in the ability of mechanical
types as reported in the literature can be seen in Table 2 instruments to negotiate around curvatures than the angle
(Bodrumlu et al., 2012; Hamasha et al., 2002; Kuzekanani of curvature. Studies have revealed that the fatigue resis-
& Sadeghi, 2019; Ledesma-Montes et al., 2019; Malcic tance of NiTi files significantly decreases if the point of
et al., 2006; Miloglu et al., 2010; Nabavizadeh et al., 2013; maximum curvature is shifted from an apical to a more
Udoye & Jafarzadeh, 2009). coronally located position (Alghamdi et al., 2020; Gao
Although all highly curved canals might be described et al., 2011; Lopes et al., 2011, 2013). Moreover, increased
as dilacerated canals, the term dilaceration is frequently length of the arc of curvature usually means a large ra-
referred to root canals that combine an increased angle of dius. The shorter the length of curvature the more abrupt
curvature with a small radius of curvature. The radius of the deviation becomes at the same degree of curvature,
curvature describes the abruptness of curvature (Pruett hence representing a smaller radius of curvature (Gao
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CHANIOTIS and ORDINOLA ZAPATA 663
Nabavizadeh et al., 2013 Bodrumlu et al., Miloglu et al., Kuzekanani and Sadeghi Udoye and Jafarzadeh (2009)
(Iran) 2012 (Turkey) 2010 (Turkey) (2019) (Iran) (Nigerian)
Prevalence Prevalence
Prevalence (Periapical) (Periapical) (Periapical) Prevalence (Periapical) Prevalence (Periapical)
4.3
0.2 0.7 0 0.5 0
0.2 4.6 3.3 0.75 2.8
0 1.8 1.1 0.50 0
0.2 2.4 3.2 1 1.7
0 2.9 5.1 1
1.3 5.8 6.7 1 4.7
0.2 4.9 5.4 0.5 3.8
5 7.4 1 3.7
4.4
0.2 0.1 0 0 0
0 0 0 0 0
0 1.3 1.3 0.75 0
0 2.2 4.6 1.25 7.5
0.2 2.7 4.3 0.25
0.7 4.9 5.3 0.50 0
1.6 5.2 5.5 0.5 1.2
10.7 12.8 3.5 1.3
4 4.3 1.65
et al., 2011). Thus, as the curve (arc) of length decreases, In routine root canal treatment, single or multiple peri-
the reduced radius of curvature will lead to an increase in apical radiographs are used. However, these images pro-
stress and strain for the instruments used for enlargement vide a two-dimensional representation of the root canal
(Gao et al., 2011). anatomy that only allows the analysis of the mesial and
Previous studies describing the characteristics of root distal curvatures (Cunningham & Senia, 1992; Stropko,
canal curvatures had one common clinical objective; the 1999). An additional proximal view angled radiograph
preoperative risk assessment to avoid procedural accidents might be able to disclose some missing anatomical features
such as transportation and unexpected instrument sepa- (Slowey, 1974). Although two off-angled projections of the
ration during clinical treatment. Moreover, measuring the anatomical features may sometimes disclose sufficient in-
geometrical anatomical characteristics of curved canals formation needed to plan the instrumentation approach,
and plotting the anatomical canal pathways might help the current CBCT imaging can provide detailed information
planning of predictable protocols to manage the challenge and eliminate most of the limitations of two-dimensional
of curved canals. Recently the techniques for measure- image (Patel, Brown, et al., 2019a; Patel, Patel, et al., 2019b).
ment of root canal curvature were reviewed with the objec- Defining the angle, radius, length, and location of the cur-
tive to address the most suitable technique for clinical and vatures in the mesio-distal and the bucco-lingual plane
research use (Hartmann et al., 2019). Although there was should allow the clinician to plan the most appropriate
a lack of consensus on the ideal technique, clinical experi- instrumentation protocol for most challenging cases of
ence and imaging-related factors were likely to influence curved and constricted canal anatomy (Schneider 1971,
the choice of technique to measure root canal curvature. Pruett et al., 1997, Schäfer et al., 2002, Gunday et al., 2005)
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664 CURVED AND CALCIFIED ROOT CANAL MANAGEMENT
(Figure 4). Recently, a CBCT-based 3D endodontic soft- canal hand instruments can be divided into three differ-
ware was introduced for the diagnostic plotting of access ent types: Reamers, K-files, and Hedström files (Schäfer,
cavity designs and canal curvatures in three dimensions. 1997). According to ISO standardization (International
This diagnostic software was suggested to decrease the Organization for Standardization, 2019), reamers are sym-
stress levels when managing calcified and curved canal bolized by a triangle, K-files by a square, Hedström files
cases (Patel, Brown, et al., 2019a; Patel, Patel, et al., 2019b). by a circle. These symbols do not necessarily represent the
true cross section of the instruments. All stainless steel in-
struments tend to straighten upon bending and are prone
I N ST RUM E NT-R E LAT E D FACTO RS to produce transportation and ledging of the root canal
trajectories. The following observations have been made
In general, instruments used in curved and constricted ca- on the use and efficacy of hand files (Tepel & Schäfer,
nals can be divided to two major categories. Instruments 1997):
that are manipulated by hand (manual instruments) and
instruments that are mounted in an engine-driven motor • Hedström files used in a linear filling working motion
(engine-driven). result in severe straightening of the curved canals by re-
moving excess material from the outer side of the apical
curvature and their use is not recommended.
Manual instruments and curved canals • Conventional stainless steel reamers and K-files caused
severe transportation of the outer curvature and re-
Instruments design and metallurgy sulted in straightening.
• Reamers and K-files made of Titanium-Aluminium re-
Early endodontic hand instruments were made from car- sulted in similar undesirable shaping effects as conven-
bon steel. Carbon steel suffered from considerable corro- tional stainless steel instruments.
sion, damage during sterilization, and a decrease in torque • Flexible stainless steel instruments with modified non-
and angular deflection (Younis, 1977). These instruments cutting tips removed material nearly equally well and
were replaced by stainless steel alloys. The mechanical performed always better in the curved canals.
property of conventional stainless steel is unaffected by
sterilization with no decrease in cutting efficiency after The main disadvantage of a 0.02 mm/mm tapered in-
several sterilization cycles. Conventional stainless steel strument is its tendency to straighten and create narrow
hand files provide excellent control and sharp long-lasting canal shapes limiting the access of irrigants and medica-
surfaces (Schäfer, 1997). However, due to the reduced ments to the apical third. Attempts at overcoming these de-
flexibility and lack of superelasticity, the efficient instru- ficiencies resulted in several instrumentation techniques
mentation of curved canals is mostly problematic. Root that aimed to decrease iatrogenic defects and produce
F I G U R E 4 Geometrical
measurements of curvature parameters.
S: Schneider Angle, CAA: Canal
Access Angle, y: Curvature Distance, x:
Curvature Height, R: Radius of Curvature,
k: Length of Curvature. (Schneider 1971,
Pruett et al. 1997, Schäfer et al. 2002,
Gunday et al. 2005).
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CHANIOTIS and ORDINOLA ZAPATA 665
preparations with a flared shape. Tapered NiTi files be- & Jones, 1992). Accoring to Allen et al. (2007) variations
came available to address this problem. The graphic repre- in design have also been considered to expand the balance
sentation of hand instrumentation techniques for curved between size, and increased rigidity, (Camps & Pertot,
canals in a chronological order can be seen in Figure 5. 1994; Cormier et al., 1988; Dearing et al., 2005; Krupp
Some of these techniques are still valid nowadays and they et al., 1984; Turpin et al., 2001). The comparison of the
are used frequently for glide path and permeabilization dimensions, physical properties, and rigidity of various
before the initiation of engine-driven instrumentation. pathfinder-type hand instruments and the evaluation of
A reproducible glide path prior to instrumentation the efficiency, wear, and distortion of these files via a lab-
is recommended to minimize procedural errors and im- oratory simulation was studied by Allen et al. (2007). The
proves the instrument shaping ability (Berutti et al., 2012). results reached relevant observations (Allen et al., 2007).
Typically, small files are necessary for initial negotiation;
however, these instruments lack the rigidity necessary • The pitch of a path-finding file influences flexibility,
to negotiate calcified canals and can often distort when tactile sense (more surface contact points), and cutting
vertical watch-winding forces are apically directed (Allen efficiency. The more flutes a path finding instrument
et al., 2007; Kobayashi, 1997). Conical instruments have has, the less flexible it becomes, and the more points
the rigidity but are too bulky to slide through a constricted of contact it uses in contributing to tactile sensation.
space (Allen et al. 2007). To solve these problems, addi- Lesser pitched instruments will be inherently more ef-
tional manual glide path finders have been introduced fective in filing but less effective in reaming (Allen et al.,
(i.e., C+ files). These files attempt to manage the difficulty 2007; Koch & Brave, 2002).
of calcified canals by modifying tip geometry, by heat tem- • The cross-sectional design of the path finding in-
pering stainless steel to increase stiffness, or by using car- strument provides information on potential rigidity,
bon steel to enhance sharpness (Allen et al., 2007; Ashby strength, and cutting ability. Most of the files in cross
F I G U R E 5 Graphic representation of manual techniques for challenging glide path securing. (a) Standardized technique (Ingle, 1961),
(b) Step-back technique (Clem, 1969), (c) Pre-curve of stainless steel files and incremental technique (Weine et al., 1970), (d) The anti-
curvature filing technique (Abou-Rass et al., 1980), (e) Step down technique (Goerig et al., 1982), (f) Double flare technique (Fava, 1983), (g)
Crown-down pressureless technique (Morgan & Montgomery, 1984), (h) The ‘balanced force’ concept for instrumentation of curved canals
(Roane et al., 1985), (i) Circumferential filing (Lim & Stock, 1987), (j) Modified double flare (Saunders & Saunders, 1992), (k) Progressive
enlargement technique (Backman et al., 1992), (l) Passive step-back technique (Torabinejad, 1994), (m) Patency and envelope of motion
(Schilder, 1974; Yu et al., 2009), (n, o) Hand instrumentation of curved canals with increased tapered Niti files (reverse-balanced force with
GT reverse fluting hand files and balanced force with ProTaper hand files; Saunders, 2005), (p) Hand instrumentation of curved canals with
increased tapered stainless steel files in 30°–30° reciprocation (flare files).
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666 CURVED AND CALCIFIED ROOT CANAL MANAGEMENT
section exhibited a nearly congruent square shank. tunnel from the canal orifice to the physiological termi-
One path finding file exhibited pentagonal geometry, nus (West, 2010). Although in most roots the anatomical
suggesting greater shank bulk than square shanked in- glide pathway is always present, the dimensions, content,
struments of similar size and taper. Other pathfinding geometry, and topography in calcified and curved canals
files exhibited D or S cross section geometry showing in- render it challenging to follow. Curved and calcified ca-
termediate shank bulk between square and pentagonal nals requiring root canal treatment might have calcifi-
and smaller shank respectively. Smaller shank dimen- cations (denticles) in sizes from 50 μm to several mm at
sions relate to less metal mass and less rigidity (Allen any level along the canal walls, pulp chamber or at the
et al., 2007; Camps & Pertot, 1994). level of the curvature (Goga, 2008). The passage of small
• One pathfinding file had greater taper and would be files to the terminus of the canal beyond the calcifications
expected to be more rigid, perhaps binding earlier in allow the clinician to establish unobstructed patency of
a constricted canal but resisting deformation because the canal before the initiation of the mechanical prepara-
of its robust quadrangular design (Allen et al., 2007; tion (Khatavkar & Hedge, 2010; West, 2010). This reduces
Camps & Pertot, 1994). the risk of ledging the curved trajectories (Young et al.,
• How efficiently an instrument traverses a canal is also 2007). In most instrumentation techniques, coronal pre-
influenced by the tip and the proximity of the initial flaring of the canal and the preparation of a glide path is
fluting to the tip. Each of the instruments had either a suggested (Berutti et al., 2009; West, 2010). Coronal pre-
conical or pyramidal tip. The pyramidal tip may better flaring has been shown to reduce the incidence of instru-
negotiate constricted canals because of increased cut- ment fracture (Roland et al., 2002). A pre-established glide
ting (Allen et al., 2007; Koch & Brave, 2002). path has been shown to reduce the stress on rotary root
• Most of the path finding files were twisted from heat- canal instruments at the tip, therefore reducing the risk of
tempered stainless steel blanks; heat tempering is a instrument fracture (Patino et al., 2005).
method of work hardening the alloy, potentially en- A glide path can be prepared with stainless steel
hancing rigidity. One path finder instrument is com- K-f iles or engine-driven instruments. The advantages
posed of carbon steel, which is initially sharper than of using K-f iles include better tactile sensation, reduced
stainless steel but quicker to corrode in the presence risk of fracture, better understanding of the anatomy
of sodium hypochlorite and sterilization procedures (when removed from curved canals, they often retain
(Allen et al., 2007; Ashby & Jones, 1992). an impression of the canal anatomy alerting the oper-
• Non-heat tempered glide path files and smaller sizes ator to the topography of the most significant curves),
are expected to have greatest degree of flexure. More and ability to be used in tortuous canals trajectories.
tapered glide path files are expected to flex less (Allen This is because they come in smaller sizes than engine-
et al., 2007; Camps & Pertot, 1994). driven glide path files. The disadvantages include the
• Some manual glide path files are available in intermedi- higher operator fatigue, the technique sensitivity espe-
ate sizes. Intermediate sizes relate to a smoother transi- cially for the inexperienced operator, the increased time
tion between sizes allowing easier passage through the required for glide path creation, the risk of introduction
canal constrictions (Allen et al., 2007; Kobayashi, 1997). of canal aberrations , change of the original anatomy,
• During simulated use, none of the files fractured. However, and the increased apical debris extrusion (Cassim &
recordable distortions including buckling, tip flattening, van der Vyver, 2013).
and tip bending were noticed (Allen et al., 2007). The advantages of engine-driven glide path files include
• File distortions were observed by only three out of the reduced instrumentation time, decreased probability for
10 clinicians involved in the simulation exercise, sug- canal aberrations (ledges, zips, foraminal transportation),
gesting that file distortion may be as much a function of better root canal anatomy preservation, reduced operator
the clinician as of the instrument (Allen et al., 2007). fatigue, and reduced apical debris extrusion. The disad-
vantages include the increased risk of torsional failure
Selection of instruments, technique, and operator when engaged inside the anatomy, the decreased tactile
skills are important parameters for the securing and the sensation, the additional cost and the limitation of their
uneventful creation of the glide path. use only after the initial glide path is secured (Cassim &
van der Vyver, 2013). It has been suggested that during
the mechanical preparation of curved and constricted ca-
Glide path nals, no engine-driven instrument should be used where
a hand instrument has not been placed before (Bergmans
The starting point of all root canal preparation procedures et al., 2001). All available NiTi engine-driven glide path
is the negotiation and securing of a smooth radicular files have non-cutting tips and because of their extreme
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CHANIOTIS and ORDINOLA ZAPATA 667
flexibility, they are not designed for the initial negotiation is inserted in the canal orifice and the file is left alone
and securing of the glide path (Young et al., 2007). to bounce to the canal direction of access. The use of
a lubricant is beneficial. The file is used with watch-
winding movements until resistance is obtained. If the
Techniques for securing the glide path file reaches length, the canal can be enlarged in a stand-
ardized approach with hand files or rotary instruments
Although hand files can produce undesirable effects dur- (Figure 5a; Ingle, 1961). As a rule, the largest the man-
ing the instrumentation, they are extremely useful for ual glidepath that can be achieved the more unevent-
the initial negotiation of curved and calcified root canals. ful the engine-driven instrumentation will be. stainless
Establishing and securing the glide path in calcified and steel files larger than size 15, 0.02 mm/mm taper be-
curved canals might be the most challenging part of the come more rigid to work around curvatures with filing
instrumentation procedure and it is mainly a hand instru- movements and should be used with the balanced force
ment procedure. Any narrow and curved pathway from technique (Roane et al., 1985), see Figure 5h. The file
the canal orifice to the radiographic foramen that blocks is inserted by using clockwise rotation and light inward
the negotiation of sizes 06–10 K-file can be defined as a pressure. The cutting is accomplished by using coun-
challenging glide path. Glide paths larger than this can be terclockwise rotation and inward pressure. Continuing
enlarged predictably with rotary or reciprocating instru- counterclockwise rotation past 120°, once the cutting
ments without the absolute need of using stainless steel is achieved, enlarges the canal to the file cutting diam-
hand files. Engine-driven glide path files will work best in eter. Furthermore, counterclockwise rotation helps to
these situations, even for inexperienced operators (Berutti ensure full diameter enlargement (Roane et al., 1985).
et al., 2009). Upon completing each cut, the file is again positioned
West (2010) described four reasons a size 10 K-file for cutting by using a clockwise placement stroke of
would not follow to the radiographic terminus and sug- one-half or less revolution. Each placement is followed
gested solutions: by a counterclockwise cutting rotation. This sequence is
repeated until working depth has been reached (Roane
a. The canal pathway might be blocked with collagen, et al. 1985). When enlargement has been accomplished,
debris, fibrotic tissue, or calcifications. The solution a final clockwise cleaning rotation is used to load canal
might be to make an abrupt apical curve on a smaller debris into the flutes and to elevate that debris away
file (typically 0.06 or 0.08), follow gently and touch from the apical foramen (Figure 5h).
the blockage, remove the file, irrigate, re-curve, and Sometimes stepping back farther from the apical
repeat until the file moves deeper (West 2010). preparation with each progressively largest hand files and
b. The angle of access and the angle of incidence are not balanced force technique might be more beneficial in a
the same. In other words, the canal might be curved in curved canal than the standardized preparation (Figure
a way that does not correspond to the curvature given 5b,l; Clem, 1969; Torabinejad, 1994). In challenging situa-
to the file used to negotiate. The solution might be pa- tions in which the file is blocked short of the radiographic
tience and randomization. (West 2010). terminus, the second step of the process of challenging
c. The diameter of the tip of the file used might be wider glidepath should be initiated.
than the canal dimensions. The solution might be as
simple as to choose a smaller file (West 2010).
d. The diameter of the shaft of the file used might be Challenging glide path securing
wider than the canal dimensions, blocking further ne-
gotiation. The solution might be either to change to a At the level of blockage, a working radiograph might be
smaller file or remove some coronal restrictive dentine beneficial to reveal the exact level and possibly the reason
and try again with the same file (West 2010). for blockage. Further apical advancement of the size 10
K-file might be hindered because of the following reasons:
To be able to secure the challenging glide path, there
are certain steps to be followed. a. The canal curvature begins at this level (Figure 6a,c,d).
b. The canal might split to two or more branches (Figure
6a).
Negotiation and glide path c. The canal might be constricted to a smaller size (Figure
6b).
Once the canal orifice is found, sizes 06–10 K-files are d. The canal content might be fibrotic, calcified, and re-
selected for initial canal exploration. The tip of the file sistant to penetration.
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668 CURVED AND CALCIFIED ROOT CANAL MANAGEMENT
F I G U R E 6 A. Mandibular premolar
with 3 canals constricted and curved. B.
Maxillary second molar showing a MB2
calcified canal at the cervical third (arrow)
and complex apical anatomy. C. Maxillary
molar with long and narrow MB root.
The arrow points the danger zone. D.
Mandibular molar showing multiplanar
curvatures in the apical third of the mesial
root.
e. The canal might have a pathological alteration of the pre-curved file negotiates below the curvature, the
internal anatomy like internal resorption and the file envelope of motion (Schilder, 1974; Yu et al., 2009)
might be stuck in the resorptive area. is applied. The file rotates clockwise by keeping a
f. The canal might have an iatrogenic alteration of the coronal resistance so that the files does not screw
anatomy such as a ledge that blocks further negotiation. deeper inside the canal. By doing this envelope of
g. The canal might have a coronal constriction that is motion, dentine is removed from the point of the
large enough to allow the tip of the size 10 K-file to ne- curvature and the radius of the curvature becomes
gotiate but not the full length of the tapered instrument slightly larger. The curvature becomes smoother and
(Figure 6b). easier to negotiate deeper with the same file (Figure
h. The canal might be iatrogenically blocked with den- 5m). Sometimes this step is enough to reach to the ra-
tinal debris from a previous attempt to negotiate. diographic terminus with watch-winding movements.
In the apical preparation, files are used in the following
The clinical techniques to manage a blocked canal are: manner. To assure accuracy, all files are measured
before pre-curving the working end. A curve is placed
a. If the canal curvature is blocking further negotiation, in the most apical portion of the file (Figure 7c).
then the length and radius of curvature must be de- The curved file is inserted into the canal and worked
termined and replicated to the scouting K-file (Figure apically using a stem-winding motion and light apical
7; Weine et al., 1970). The pre-curved file must be pressure. Once the file reached WL, it is withdrawn
smoothly guided to the same spot without pressure several mm, then worked to length and withdrawn
and with watch-winding movements (Figure 5c). In again (Figure 5k). This sequence is repeated until the
cases of small radius curvatures (abrupt), pre-flaring file can slide easily to WL without using the stem-
of the canal orifice is usually required so that the winding motion (progressive enlargement technique;
pre-curved file can fit inside the canal. Once inside Backman et al., 1992). Directional anti-curvature filing
the canal, the file is slowly guided up to the level (Figure 5d) or circumferential filing (Figure 5i) of
of the blockage. At this point, the pre-curved file less than 0.5 mm amplitudes with the size 10 K-
is rotated clockwise or counterclockwise so that the file will smoothen the curvature before starting the
tip of the file faces the inner side of the curve. The automated instrumentation (Abou-Rass et al., 1980;
objective is for the tip of the file to negotiate below Lim & Stock, 1987). With a size 10 K-file becoming
the curvature (Figure 7a,b). A notched silicon stop extremely loose, the rotary/reciprocating instrumen-
in the shaft of the hand file is used to control the tation can be safely initiated. In severe curvatures,
movement of the tip of the pre-curved file. Once the larger taper nickel-titanium manual files can be also
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CHANIOTIS and ORDINOLA ZAPATA 669
F I G U R E 7 a. S-shaped transparent training model with a 15 K file extruding the apical exit and measuring bars for the calculation of
the radius (DRSK training models, drsk.com, Sweden), b. Radiographic projection of the double curved training model and calculation of
the curvature radius (5mm radius middle third curvature, 3mm radius apical third curvature), c. Endo-Bender instrument (Sybron Endo) is
used to replicate curvatures of different radius in stainless steel K files. The pre-curved files are used to negotiate below the corresponding
curvatures.
used safely with balance force movements (Figure d. If the canal below the blockage is calcified or fibrotic,
5o) or reverse-balanced force (Figure 5n) in files of the tissue might resist further penetration. The solu-
reverse direction flute design (Saunders, 2005). tion is the use of stiffer files that can withstand more
b. Blockage because of splitting canals can be managed pressure. Abundant irrigation with NaOCl solutions
the same way as curved canals with the only differ- alternative with EDTA 17% might be able to soften the
ence that the canal curves simultaneously to more fibrotic or calcified tissues respectively and allow fur-
than one direction. Each direction followed will lead ther file penetration (Hülsmann et al., 2003; Zehnder,
into a different canal. A preoperative CBCT is very 2006). If a combination with curved pathways exists,
helpful to understand the topography and number of then the curved pathway management protocol should
the splitting canals. The magnification and illumina- be followed with stiffer pre-curved files and the same
tion provided by an operating microscope are indis- motion.
pensable tools in cases with deep splitting pathways. e. Pathologic alterations of the internal anatomy (internal
Visualization of the splitting point under the micro- resorption).
scope will facilitate the negotiation and securing of f. Iatrogenic alterations of the internal anatomy (ledges,
the glide paths. Straight line access and enlarging the perforations). If a pathologic or iatrogenic alteration of
canal above the splitting point will facilitate addition- the internal anatomy exists, the curved management
ally the whole procedure and will provide a visual protocol should be followed. Each alteration of the in-
corridor to the different branches of the split. Once ternal anatomy, pathologic or iatrogenic, can be trans-
the glide path in all branches is secured, rotary instru- lated and correspond to a curve. The radius of this curve
mentation can be initiated (Figure 8). is replicated in the file and the canal below the altera-
c. If the canal is smaller than size 10 K-file, the solution tion or the ledge can be negotiated. Once the alteration
might be as simple as choosing a smaller size 0.08 or is bypassed, short amplitude push and pull movements
0.06 file. If a combination of curvature and smaller of the file can smoothen the pathway and render it re-
canal exists, then the curved pathway management producible and secured. Very useful in these situations
protocol should be followed with smaller files. If a com- are stainless steel hand files with larger tapers. These
bination of splitting and smaller canal exists, then the files can be used in 30°–30° CW-CCW manual motion
pathways below the splitting point should be followed or even mounted in a special reciprocating handpiece
with smaller files. (M4 handpiece, Sybron Endo) reducing hand fatigue
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670 CURVED AND CALCIFIED ROOT CANAL MANAGEMENT
FIGURE 8 Mandibular first premolar with a previously initiated treatment and symptomatic apical periodontitis. Unusual anatomy,
intracanal medication at the coronal third, and calcified canals are observed in the preoperative image (a). Number 6 and 8 C+ hand
instruments in the MB, DB and lingual canal. Instrumentation was completed by hand files ISO# 06-15, and .04 NiTi instruments. (C-D)
cone fit and obturation of the case. Note the access cavity before and after the refinement with ultrasonic tips (e-g).
and accelerating the whole securing procedure (Figure i. In some cases, combination of two or more of the
5p). above solutions might be required to secure the glide
g. The securing of the glide path in canals that have a path. Changing between the different solutions back
coronal constriction can be easily managed with re- and forth might also be required to achieve a successful
moval of the coronal constriction with flaring (Figure glide path securing outcome.
5f,j; Fava, 1983; Saunders & Saunders, 1992) or the
crown-down sequence of manual files and gates- The challenging glide path securing should be effec-
Glidden burs (Figure 5e,g; Goerig et al., 1982; Morgan tively managed by following the suggested steps prior to
& Montgomery, 1984). any engine-driven instrumentation. The preparation of
h. Iatrogenic blockage needs stiff instruments and abun- a glide path prior to shaping with engine-driven instru-
dant irrigation to overcome. Fibrotic or calcified ments has been shown to provide better results in terms of
pathways resist file advancement. The techniques de- mechanical failure, shaping ability, apical debris extrusion
scribed above might be difficult to work if the canal is and dentinal defect formation, when compared with the
blocked. To unblock the pathways, frequent irrigation absence of glide path creation (Berutti et al., 2012; Kwak
is needed with alternative use of a chelator and sodium et al., 2018).
hypochlorite (Hülsmann et al., 2003; Zehnder, 2006).
The chelator will act in the inorganic component of
dentinal mud blockage exposing collagenous matrix. Engine-driven instruments and
The exposed organic collagenous matrix can be dis- curved canals
solved with sodium hypochlorite. The use of stiff pre-
curved instruments in combination with the suggested If the absence of curvature, conventional stainless steel
irrigation protocol might provide a small pathway for files would have results as good as the one produced
penetration of the files to WL. Once WL is reached, a by nickel-titanium instruments. Stainless steel files
change to softer K-files is required for further secur- can maintain sharp edges longer. Unfortunately, most
ing of the glide path with minimal deviations from the of the canals in the human dentition are curved. Root
initial pathway. canal curvatures can cause excessive torsional stresses
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CHANIOTIS and ORDINOLA ZAPATA 671
and cyclic fatigue on conventional stainless steel files 11. The greater the number of flutes with similar helix an-
resulting in undesirable canal transportation and in- gles, the greater the tendency of the file to screw into
strument separation. Moreover, hand instrumentation the canal and become bound.
can extrude debris or push them laterally into the lat- 12. Maximum engagement of a file occurs when it pro-
eralanatomy. In contrast, mechanical instrumentation gresses into the canal at a rate that is equal to its feed
can collect and remove debris from the canal system rate, the rate the file progresses into the canal without
in a coronal direction. The introduction of NiTi al- the application of positive or negative pressure.
loys allowed the manufacturing of tapered files that 13. Less canal transportation occurs with a file having
can be used with rotation or reciprocation movements greater flexibility, an asymmetrical cross section de-
(Baumann, 2004; Walia et al., 1988). Innovations sign, and/or a land.
adopted by manufacturers has allowed the production
of new NiTi alloys. The hybridization of new systems Incorporating designs and techniques to reduce
provides greater security and adaptability for curved ca- any of these forces is very important in curved canal
nals management. management.
Nowadays, more than 200 different engine-driven instru- The mechanical properties of NiTi alloys for curved canal
ments are available in the market. It is imperative to rec- management vary according to their chemical composi-
ognize instrument features that improve efficacy or pose tion and thermal treatment during manufacturing (Figure
possible risks for curved canal management. 3d). Heat treatments consist of controlled heating and
The following considerations are important in formu- cooling under controlled conditions to obtain specific
lating techniques to approach difficult cases (McSpadden, properties that will improve clinical behaviour (Shen
2007): et al., 2011). The heat treatments performed to improve
the NiTi alloy properties might be beneficial for the man-
1. A file with a more efficient cutting design requires agement of curved and constricted canals and include in
less torque, pressure, or time to accomplish root canal chronological order (Gavini et al., 2018):
enlargement.
2. In a straight canal, the ability of a file to withstand tor- • Electropolishing (electrochemical surface treatment;
sion is related to the square of its diameter. 1999): It is a surface treatment leading to the reduc-
3. In a curved canal, the ability of a file to resist fatigue tion of manufacturing defects with the goal to increase
has an inverse relationship with the square of its the cutting efficiency and fatigue resistance of the file
diameter. (Gavini et al., 2018; Anderson et al., 2007).
4. The torque required to rotate a file varies directly • M-wire (2007): It is a unique thermomechanical pro-
with the surface area of the file's engagement in the cedure at various temperatures, applied before the
canal. machining of a new Niti alloy composed of 55.8% Ni.
5. Fatigue of a file increases with the number of rota- The final alloy contains both martensitic and R phases
tions of the file in a curvature. whilst maintaining the pseudoplasticity. The objective is
6. Fatigue of a file increases with the degree of curvature to produce an instrument of higher cyclic fatigue resis-
of the canal. tance and enhanced mechanical properties compared to
7. To improve efficiency, the smaller the surface area conventional superelastic NiTi files (Gambarini et al.,
of a file engaged in the canal, the greater the rotation 2008, 2011; Gavini et al., 2018).
speed should be. • R-phase (2008): It is a thermomechanical procedure
8. The more spirals a flute has per unit length around that generates an additional R-phase change in the crys-
the shaft of a ground file, the less resistance to tor- tal structure of the alloy. This allows twisting of the wire
sion deformation there is, but the more flexible the rod to create the flutes by plastic deformation and heat
file is. treating it to recrystallization. It improves flexibility and
9. The fewer spirals a flute has per unit length around strength. An additional special oxidation bath surface
the shaft of a ground file, the more it resists torsion treatment increases the hardness of the file without
deformation, but the more rigid it is. changing its flexibility. This twisting process ensures
10. The sharper the cutting blade of a file, the fewer spi- greater resistance than grinded instruments (Gambarini
rals per unit length the file should have. et al., 2010; Gavini et al., 2018).
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672 CURVED AND CALCIFIED ROOT CANAL MANAGEMENT
• CM wire (2010): The nitinol SE508 alloy is machined force, are ideal properties for the management of curved
and subjected to a heating and cooling process that and calcified canals (Figure 3d). Although instrument de-
will give the alloy control over the shape memory ef- signs and metallurgy are relevant steps for the manage-
fect, allowing the instruments to be free from restoring ment of curved canals, developing a consistent technique
forces, more flexible and fatigue resistant (Gavini et al., to use these instruments is even more important.
2018). These instruments present less nickel (52%) than
conventional alloys (54%–57%). The Af temperature of
CM files is 470 C suggesting that at room and body tem- Engine-driven instrumentation techniques
perature, the instrument is composed from martensite,
R-phase, and some austenite compared to conventional General engine-driven technique considerations
NiTi which is purely austenitic. Although CM files have McSpadden (2007) suggested nine considerations for the
lower tensile strength than conventional alloys, they safer engine-driven instrumentation of curved canals with
have a higher capacity to withstand deformation before superelastic NiTi files (McSpadden, 2007):
fracture (Gavini et al., 2018), indicating their superior
flexibility. The reduction of the restoring forces, the ex- 1. Select the tip design that will not burnish or transport
treme fatigue resistance and the superior flexibility ren- the canal (non-cutting guiding tips).
der these instruments ideal to be used in curved canals 2. Advance a file into the canal with no more than 1 mm
(Bürklein et al., 2014; Gavini et al., 2018). increments with insert/withdraw motions (usually
• CM Blue Wire & CM Gold Wire (2012 & 2014): It is a heat three pecking movements and remove to clean flutes
treatment process for NiTi CM alloys , theinstruments and canal).
are continuosly heat-treated and then cooled, which 3. To advance a particular file the first 1 mm into a
results in a surface colour corresponding to the thick- canal after it becomes engaged, a minimal specific
ness of the layer of titanium oxide (Gavini et al.,2018). pressure needs to be applied (feed rate of the file). If
In the NiTi Blue Wire alloy, the thickness ois 60–80 nm, the pressure to advance the file needs to be increased
whereas in the NiTi Gold alloy, this thickness is 100– above the level of its feed rate or if a negative pres-
140 nm (Gavini et al.,2018). The rigid titanium oxide sure (screwing-in force) is encountered, change to
layer compensates for the loss of hardness enhancing a smaller sized and tapered file or circumferentially
cutting efficiency and wear resistance (Gavini et al., file coronal to this position will minimize the applied
2018). These systems also have better fatigue resistance stresses.
and flexibility for curved canal management (Plotino 4. File advancement into the canal should be able to occur
et al., 2014; Gavini et al., 2018). at a rate of at least ½ mm per second without increas-
• Max Wire (2015): This heat treatment results in an in- ing the pressure for insertions.
strument that at temperatures greater than 35°C, shifts 5. If a file has more than a 0.02 taper, do not advance more
from the martensitic to the austenitic phase (Gavini than 2 mm beyond the preparation of the previous file
et al., 2018). This providesthe instrument a semi-circular if any part of the file is engaged in a curvature.
shape that allows it to project against the walls of the root 6. Except for 0.02 tapered files having a size diameter of
canal when rotating, performing eccentric rotary motion 0.20 mm and smaller, do not engage more than 6 mm
(Gavini et al., 2018). The main purpose of this instrument of the file's working surface if the file is engaged in a
was to provide supplementary cleaning of the canal at the curvature.
end of chemical and mechanical preparation, (Bao et al., 7. Apply light apical pressure on any file whilst advanc-
2017; Gavini., 2018)). Recently, a shaping Max Wire in- ing into the canal and try to avoid negative (screw in)
strument also became available (Gavini et al., 2018). forces around curvatures by using smaller tapered files
• EDM Wire (2016): NiTi CM 495 alloy is manufactured and files of asymmetrical cross section.
using spark erosion technology. The EDM manufactur- 8. Beyond the point of curvature in the apical zone, the
ing method seems to improve the fracture strength and file diameter should be no greater than 0.60 mm for a
cutting efficiency of the instruments. XRD analysis of 0.02 taper, 0.55 mm for 0.04 taper, 0.50 mm for 0.06
these instruments revealed the presence of monoclinic taper, and 0.35 mm for a 0.08 taper. (This considera-
martensite B19 structure and rhombohedral R-phase tion is the result of testing for 45° curvatures having
(Iacono et al., 2017; Gavini et al., 2018). 8 mm radii and applies only to these dimensions for
rotary conventional NiTi files. File diameters should be
The Improved flexibility and high cyclic fatigue of heat- smaller for more severe curvatures and can be adjusted
treated NiTi files, combined with the lack of restoring larger for less severe ones.)
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CHANIOTIS and ORDINOLA ZAPATA 673
9. When any of the parameters cannot be met, changing to that determination is the force required for rotating a file
a file having a different taper in the technique sequence relative to the force necessary to progress through the
will usually enable re-adherence to the parameters. curvature (McSpadden, 2007). A severe curvature in the
apical third of the canal could be less threatening than a
Adherence to these principles combined with frequent moderate curvature in the mid-root or the cervical portion
irrigation, patency maintenance, and cleaning of the flutes of the canal. The ability of an instrument to resist the cyclic
can ensure an uneventful shaping for most rotary sys- fatigue has an inverse relationship with the square of its
tems (McSpadden, 2007). However, in challenging highly diameter. The same inverse relationship applies also for
curved and constricted root canals, these general consid- the flexibility (McSpadden, 2007). Therefore, the smaller
erations might not be always adequate to accomplish the diameter tip of a file can negotiate an apical curvature
goals of treatment. For these cases, several instrumenta- easier than the larger diameter portion can negotiate the
tion techniques have been established and reported in the same amount of curvature in the coronal or mid-root part
literature. Although the following engine-driven instru- of the canal (McSpadden, 2007).
mentation techniques are suggested to provide solutions According to the testing of instruments for 45° curva-
in complicated clinical scenarios, independent studies tures having 8 mm radii, McSpadden (2007) introduced
evaluating their safety, validity, and reproducibility are some file diameter limitations that should not be exceeded
still lacking. during rotary instrumentation with conventional austen-
itic NiTi files. Beyond the point of the curvature, the rotary
Specialized engine-driven technique considerations NiTi file diameter should be no greater than 0.60 mm for a
The zone technique. This technique was developed by 0.02 taper, 0.55 mm for a 0.04 taper, 0.50 mm for a 0.06 taper
McSpadden (2007). During root canal instrumentation and 0.35 mm for a 0.08 taper (McSpadden, 2007). For more
of curved canals, variations in the pressure required for severe curvatures, the file diameter limitations should be
progressing into the canal determine if the curvatures smaller and for less severe curvatures could be larger.
are threatening for the file used (McSpadden, 2007; Taking into consideration the diameter limitations
Figure 9a). One of the greatest challenges in making for 45° curvature with 8 mm radius, McSpadden (2007)
(a) (b)
(c) (d)
F I G U R E 9 A. Graphic representation of the Zone technique (Coronal zone, apical zone and protocol diameters are represented)
(McSpadden 2007), B. 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), C. Graphic representation of the stationary, in-stroke and out-stroke steps of the single
stroke Tactile Controlled Activation (TCA) technique (Chaniotis & Filippatos 2017), D. Graphic representation of the maximum coronal
zone flaring depth calculation for dentine preservation and the 3- stroke apical zone file activation below the curvature according to the
arithmetic crown-down dynamic tactile instrumentation technique (Elkholy & Ha 2021).
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674 CURVED AND CALCIFIED ROOT CANAL MANAGEMENT
introduced the zone technique with two objectives in 6.25 mm. Since the length of the apical zone is 6 mm, the
mind to minimize file stress for any type of NiTi rotary file 30/04 file can be rotated to full length with relative safety.
used for the preparation of curved canals. First, the canal Before reaching the apical zone with rotary files, the cor-
diameter coronal to the curvature should be large enough onal zone needs to be enlarged to a size 0.30 + (6 × 0.04)
to prevent any engagement in that portion of the canal = 0.30 + 0.24 = 0.54 mm to prevent any engagement in
when any file is being used apical to the curvature, and that point of the canal whilst using the 30/04 file to length.
second, the file diameter is not too large to rotate safely in A common mistake is to use tip diameters at the termi-
a curvature. nus of the coronal zone that are smaller at that point than
The technique is divided into two steps. the diameters for files used in the apical zone. Care must
be taken not to ledge and alter the root canal anatomy at
a. Step one. Determine if there is a curvature of any the terminus of the coronal zone. This can be achieved
significance and how far the curvature is from the by frequent recapitulations with small stainless steel hand
apex. Dividing the canal into zones according to the files and adherence to the estimated coronal zone length.
location of the curvatures or constrictions in relation File sequencing can be flexible if it adheres to the princi-
to the apex can simplify canal preparation with each ples. If the target of the desired final apical enlargement
zone having a different technique. Initial methods for is 30/06, then according to the previous formula, the di-
dividing the canal into zones relied on the tactile ameter limitation of 0.50 (−) tip size 0.30 = 0.20 (÷) taper
feedback during file insertion. With a non-rotating 0.06 = 3.33 mm. This means that a 30/06 file can be safely
file smaller than the canal passively advanced, the projected around the curvature in the apical zone only for
depth at which resistance is met denotes the terminus 3.33 mm. The 30/06 file is not safe to use to full length
of the coronal zone and the beginning of the canal since the length of the apical zone below the curvature is
deviation. With a rotating file, the coronal zone is 6 mm. The desired final preparation for the canal needs to
denoted whenever the pressure needed for additional be rearranged to fit the diameter limitations. The final en-
advancement to occur, whilst using 1 mm increments, largement can shift to a shape of smaller taper or smaller
is exceeded. Nowadays, the coronal and apical zones tip size to fit the diameter limitations.
can be determined three dimensionally with the use Diameter limitations in canals having different curva-
of CBCT imaging and specific software. tures can be extrapolated mathematically. Two factors are
b. Step two. Determine the distance each of the files hav- to be considered, the WL and the radius of curvature. If
ing different sizes and tapers can safely be advanced the radius is 16 mm (two times the amount stated in the
around curvatures and which size file will need to be parameters), the diameter limitation of a 06 taper file is
used in the coronal zone to prevent any subsequent file larger than 50 based on the square of the file diameter. For
from binding in the apical zone. cases with an apical zone greater than 6 mm, curvature
more than 45° and radius less than 8 mm, the diameter
By using the diameter limitations for a curvature of 45° limitations should be smaller.
and 8 mm radii, the following formula is suggested: Although the calculations seem complicated, with
some practice this technique can be mastered with the
Length that the file can be projected around the curvature
diameter limitation − file tip size benefit of efficiency and the reduction of the threat of fail-
= ure. However, if a technique is required for routine cases
file taper
with an apical zone of 6 mm, 45° curvature and 8 mm ra-
dius, the following technique is suggested with conven-
(Diameter limitations: no more than 0.60 mm for 0.02 tional austenitic NiTi rotary files:
taper, 0.55 mm for 0.04 taper, 0.50 mm for 0.06 taper and
0.35 mm for 0.08 taper). 25/06 to curvature
For example: The WL of a curved canal with an angle 55/06 to curvature
of 45° and 8 mm radius is 16 mm (apical and coronal 25/02 to WL
zone). The intended enlargement of the canal according 25/04 to WL
to the initial canal dimensions is aimed at 30/04. The cur- 26/06 1 mm short of WL (Figure 9a).
vature length from the point that the canal starts to devi-
ate to the apical foramen is 6 mm (apical zone). According For root canals with different angle than 45° and dif-
to the formula suggested, 0.55 is the diameter limitations ferent radius than 8 mm, appropriate adjustment of the
for 0.04 tapered files (−)0.30 tip diameter equals (=)0.25, above protocol is required.
divided by 0.04 equals 6.25. The length of the 30/04 file If more flexible and fatigue-resistant martensitic heat-
that can be projected safely beyond the given curvature is treated rotary NiTi files are to be used with the zone
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CHANIOTIS and ORDINOLA ZAPATA 675
technique, the suggested diameter limitations will have to treatment can allow the instrumentation of challenging
be re-adjusted to larger sizes for the same parameters of curvatures with this technique. (Figure 10).
curvature. This adjustment will result in the ability to de-
liver larger apical preparations during the enlargement of Tactile Controlled Activation (TCA) technique. Keeping
curved root canals. The enlargement technique also will in mind the complexity of root canal systems and the need
have to be re-adjusted to accommodate larger preparations to minimize file engagement and torsional loading during
with heat-treated files. Although the diameter limitations instrumentation of dilacerated canals, a novel approach
of the zone technique were tested by McSpadden (2007), was developed and named Tactile Controlled Activation
independent scientific evidence supporting these limita- (TCA) instrumentation technique (Chaniotis & Filippatos,
tions and the suggested adjustments are lacking. Until fur- 2017a,b; Figure 9c). The TCA technique can be defined as
ther evidence becomes available, these limitations should the single stroke activation of a motionless (stationary)
be applied with caution. engine-driven file only after it becomes fully engaged
inside a patent canal and tactile feedback of the underlying
Reciprocating technique. Another development in root anatomy is gained (Chaniotis & Filippatos, 2017a,b). TCA
canal preparation was the introduction of reciprocating utilizes file activation only after maximum engagement
techniques (Bürklein et al., 2012; Yared, 2008; Figure of the file below the fulcrum of the curvature is achieved
9b). Rotary nickel-titanium (NiTi) instruments have and tactile feedback of the anatomy and topography of
already enhanced the quality of root canal shaping the curve is gained. By inserting non-rotating files with
minimizing procedural accidents (Schäfer et al., 2004). smaller diameters around curvatures and withdrawing
With the introduction of single file reciprocating with rotation, the severity of the curvature can be easily
instruments, it was claimed that the management of determined whilst avoiding excessive stress (McSpadden,
curved canals can be obtained with a single instrument. 2007). TCA technique is taking advantage of this strategy
In some cases this step can be obtained without prior to avoid stress in highly curved canal systems. It can be
glide path preparation. This outcome can be explained divided into three phases: stationary, in-stroke, and out-
by the reciprocating movement. The instruments cut stroke (Figure 9c).
dentine in a counterclockwise (CCW) direction and are Stationary phase: After accessing the pulp chamber and
released in a clockwise (CW) motion. The instrument locating the canal orifices, technical patency to the apical
will progress into the root canal because the CW rotation third is achieved and the glide path is secured at least up to
is smaller than the CCW rotation (Plotino et al., 2015). size 10, 0.02 taper. After the glide path is secured, the first
The releasing motion removes the stress from the automated file to be used should be preferably of equal
instrument and prevents instrument fracture (Plotino or slightly larger tip size depending on the location, the
et al., 2015). Because of the reciprocating motion, the angle, and the abruptness of the curvature along the root
instruments should follow the naturally existent root length. The taper of the first engine-driven file should be
canal path down to the apical ending of the canal (Yared, 4% or less. The file is mounted on the handpiece of an end-
2008). Previous authors reported that a large proportion odontic motor and passively inserted inside the canal until
of non-calcified root canals can be prepared with the maximum frictional resistance is met. In hard-to-reach
Reciproc instrument without a previous glide path areas, the stationary engine-driven file can be inserted by
preparation (De-Deus et al., 2013; Zuolo et al., 2015). hand until resistance and the motor can be connected in-
The ability of the reciprocation technique to achieve the traorally afterwards before starting the next phase.
WL in straight canals without glide path is 96.4%, and for In-stroke phase: Before activating the file, it needs to be
moderately curved canals is 90.7% (De-Deus et al., 2013). verified that the tip of the file passed the first curvature.
The movement suggested with the reciprocating files is 3 This can be verified with a radiograph (TCA-radiograph)
pecking insertions with less than 1 mm amplitude. The or by keeping strict recordings of the depth of the curva-
instrument is clean and the movement is repeated until ture. Once the file position is verified, the file is activated
the instrument reachesthe working length (Figure 9b). As and pushed slightly apically (in-stroke) until the activated
a practical rule, in reciprocating systems, it is suggested file resists further advancement below the curvature.
that if a straight stainless steel size 0.8 K-file cannot Out-stroke phase: Once the first resistance is met, the
reach the full WL, then a glide path procedure is needed . file is withdrawn from the canal without applying fur-
If a straight size 0.8 K-file can reach easily WL, then ther apical pressure to go deeper (single stroke). During
the glide path securing procedure might not be always withdrawal, the file can be pushed towards the bulkier
required. However, even with the reciprocating systems, root structure away from the curvature and the thinner
a glide path will always facilitate the instrumentation danger zone (anti-curvature out-stroke). The single in-
procedures. The introduction of glide path files and heat stroke and out-stroke technique eliminates the risk of
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676 CURVED AND CALCIFIED ROOT CANAL MANAGEMENT
F I G U R E 1 0 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 the root structure and a three-dimensional filling in the MB root.
torsional failure of the file that will be activated inside (McSpadden, 2007) and the TCA technique (Chaniotis &
the canal because the file will be moved from the point Filippatos, 2017a,b; Elkholy & Ha, 2021; Figure 9d). The
of maximum engagement without activation to a point zone technique has the limitation of focusing on the length
of no engagement with activation. This single movement of file engagement without calculating the maximum
will remove coronal restrictive dentin facilitating the next insertion depths of higher tapered instruments to prevent
single strokes without risking torsional failure. Once the over flaring of the canal and preserve pericervical dentine.
file is removed, the flutes are cleaned and checked for any TCA involves a single activation upon engagement in the
possible deformations followed by irrigation of the canal curvature and immediately redrawing the file resulting in
and patency confirmation. In the next stationary phase, increased preparation time, whilst coronal flaring is not a
the same file will bind deeper inside the canal passed the prerequisite for this technique and can result in reduced
curvature. The same cycle is repeated with the same file tactile feedback. To overcome these problems and avoid
in a crown-down approach until the file reaches WL. The over preparation of the cervical part of the curved canal, a
work to be done by each file is completed when the file new technique was introduced and named as the arithmetic
can reach WL without having to activate it (stationary). crown-down dynamic tactile instrumentation technique.
After reaching WL, progressive enlargement is continued The technique is divided into the following steps
in the same way until the desired apical instrumentation (Elkholy & Ha, 2021):
width and canal taper is accomplished (Figure 9c). Ideal
instruments for TCA technique are the flexible marten- Step 1: Determination of zones
sitic instruments that are free from restoring forces. The A preoperative radiograph is taken to determine the
TCA technique is not recommended with austenitic NiTi estimated length and divide the curved canal in two
files having restoring forces because of the risk of ledging zones: the coronal and apical zone. In a canal with ini-
when activated inside the curvature. The TCA technique tial estimated length of 22 mm, the boundary between
aims at the delivery of adequate apical preparations in the coronal zone and the apical zone is 16 mm from the
highly curved canals by minimizing the time of engage- incisal edge and 6 mm from the apex.
ment of the activated files around curvatures (Figures 11 Step 2: Coronal zone flaring
and 12). Although the TCA technique described as being Coronal flaring is achieved before confirmation of WL
safe, even for the most challenging curvatures, indepen- and the establishment of the glide path. The depth of
dent studies to evaluate the limits of this technique are insertion of the flaring instrument, whilst prevent-
still lacking, and it should be applied with caution and ing overenlargement, is calculated with the following
after practice on extracted teeth. equation:
S −S + Tfinal × 16
f = 16 − final current
T current
Arithmetic crown-down dynamic tactile instrumentation
technique. This instrumentation technique proposed f: the maximum placement of a coronal flaring instru-
by Elkholy & Ha (2021) combines the zone technique ment that does not flare the canal wider than the final
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CHANIOTIS and ORDINOLA ZAPATA 677
(d) (e)
F I G U R E 1 1 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
radiograph revealing the curvature parameters in the bucco-lingual plane.
(e) (f)
F I G U R E 1 2 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).
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678 CURVED AND CALCIFIED ROOT CANAL MANAGEMENT
intended shaping instrument. This measurement is rel- of the first curvature, a TCA needs to be applied. The
ative to the apex and will be short of WL file is inserted passively into the canal until engage-
16: the boundary between the coronal and the apical ment of the walls is tactilely felt and then activated to
zone as measured from the reference point resistance with activation and redrew from the canal
Sfinal: the final intended apical size (ISO) without exceeding the 17.5 mm boundary (Chaniotis &
Tfinal: the taper (%) of the final intended apical size Filippatos, 2017a,b). Although the original technique
Scurrent: the apical size (ISO) of the crown-down described suggested a single stroke and remove action,
instrument a modification of three strokes of less than 0.5 mm am-
Tcurrent: the taper (%) plitude is suggested to expedite the procedure.
The depth of insertion of the coronal flaring instru- Step 5: Apical zone finishing
ment can be determined by the following equation: After coronal flaring and apical zone flaring, pre-
Lcurrent = Lfinal − f curved martensitic files are inserted into the canal
For example: If the first flaring instrument is 17/12 and pointing towards the curvature, engaging the walls
the final apical enlargement 30/04, by using the first of the canal and activated until reaching the WL with
equation: three gentle apical strokes instead of one at a time as
f = 16 − 30 − 1712+ 4 × 16 = 9.6 mm short of WL. described in the original TCA technique. The sequence
suggested is a standardized technique until a size 30,
If the estimated length is 22 mm, then the 17/12 orifice 0.04 taper enlargement can be achieved. The apical
opener could be placed to 12.4 mm from the reference curvature file engagement can be minimized by using
point. Beyond this point, overflaring the coronal third a sequence of size 20, 0.04 taper, size 25, 0.04 taper and
of canal would occur. size 30, 0.04 taper to full WL. In more challenging anat-
The files are suggested in a gentle pecking motion omies,smaller size martensitic files might be needed to
not exceeding 1 mm per stroke and maximum three reach the WL (Figure 9d).
strokes.
If the next additional flaring instrument to be used just The kinematics of the TCA technique by passively
around the curvature is a 25/06 file, according to the inserting a file until it engages the canal wall followed
equations this file can be inserted by activation and withdrawal allows optimum canal en-
f = 16 − 30 − 256+ 4 × 16 = 4.5 mm short of WL gagement for cutting and avoids unnecessary stresses.
The modified TCA suggested for the apical curvature en-
or largement is feasible because of the combination of cor-
Lcurrent = 22 − 4.5 = 17.5 mm from the reference onal and apical zone flaring that minimizes the stresses
point. and allows more TCA strokes to take place with minimal
Although the second flaring file can be inserted to engagement. However, multiple strokes should be applied
17.5 mm, it is suggested not to exceed the boundary always with caution and only after careful evaluation of
of the curvature before the glide path is established anatomical and instrument parameters.
(boundary is 16 mm).
Step 3: Canal negotiation, WL, glide path and con-
firming curvature analysis (securing the glide DISINFECTION- R ELATED FACTO RS
path)
Canal negotiation and patency can be obtained at this Root canal curvature, as an anatomic factor, can influ-
stage using size 08 K-file followed by WL confirmation ence the chemo-mechanical preparation. Curved and
with an electronic apex locator. The glide path can be constricted canals tend to be enlarged to smaller apical
enlarged up to a size 10 K-file and the zones can be con- preparations reducing the available space for effective
firmed. In some curved canals, the glide path creation disinfection. The ability of an irrigant solution to be dis-
can be challenging to secure. All the techniques to tributed in the apical third depends upon the following
secure the challenging glide path that were described factors:
earlier in this article might be used at this step.
Step 4: Apical advancement • The irrigation delivery technique
After securing the glide path and confirming the bound- • The level of the needle penetration
aries of the first canal curvature the size 25, 0.06 taper • The type and gauge of the needle
flaring file can be inserted to the 17.5 mm from the ref- • The canal anatomy
erence point boundary as calculated by the equations. • The final size and taper of root canal preparation
Since this depth of insertion is beyond the boundary • The irrigant activation techniques used
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CHANIOTIS and ORDINOLA ZAPATA 679
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680 CURVED AND CALCIFIED ROOT CANAL MANAGEMENT
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CHANIOTIS and ORDINOLA ZAPATA 681
Cassim, I. & van der Vyver, P.J. (2013) The importance of glide path Society of Endodontology. International Endodontic Journal,
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