Traditionally, rotary Ni-Ti (RNT) choices for canal enlargement were either safe or

efficient and rarely, if ever, both simultaneously in all anatomies. Safe files were
fracture-resistant but may not have cut as effectively as their efficient counterparts.
Efficient files cut well and yet broke more often and had a greater risk of canal
transportation. This inherent lack of both safety and efficiency is now a thing of the
past. The introduction of the Twisted File (TF [Sybron-Endo]) represents a huge step
forward for endodontic canal preparation. It is truly safe and efficient. TF is very
difficult to fracture if used as directed and has excellent cutting efficiency without
undue risk of transportation.
Inherent to the challenges manufacturers face is that grinding nickel titanium has
always had to be performed against the grain structure of the metal. Grinding has the
potential to create microcracks that can later be the focal point for failure due to excess torsion and cyclic fatigue. Some brands of files have been electro-polished to
reduce the effects of these microcracks (in theory); yet such electro-polishing may
reduce the sharpness of the cutting edge and removes some amount of the surface
layer of the metal. A comprehensive summary of the design features of all RNT files
available in North America today is beyond the scope of this article. Suffice it to say
that the designs currently available have been dictated, to one extent or another, by the
limits imposed by grinding nickel titanium, among other secondary factors.
THE HISTORY BEHIND TF TECHNOLOGY
Figure 1. The grain structure of the Twisted File (TF) that is never cut across in its
manufacture.
Nickel titanium in endodontics was introduced because the metal is superelastic. In its
natural resting state, the material is in a crystalline structure known as austenite. When
subjected to rotation in the canal, it is superelastic in that it undergoes a
transformation to a crystalline structure known as martensite. When the stress is
relieved, the material reverts to the crystalline structure of austenite. The
transformation is superelastic in that the material regains its original shape when it
reverts to its original crystalline structure.
Through a proprietary process of machining, heating, cooling, twisting, reheating,
and cooling, TF is never ground against the grain structure (Figure 1). Through the
first heating process, nickel titanium is placed in a state known as R phase (a state that
might be thought of as a crystalline structure that is intermediate between austenite
and martensite). While in R phase, the material can be twisted very precisely. The
second cooling phase makes the precise twisting permanent while bringing the
material back into the austenite crystalline structure. Twisting nickel titanium does not
disrupt the grain structure of the metal and allows it to keep its inherent strength. The
final TF file is subjected to a surface conditioning that maintains its surface hardness
and properties.
ADVANTAGES OF TF
Figure 2a. The Twisted File. Figure 2b. The Twisted File Large Pack Assortment
(.10, .08, and .06 tapered TF).

Figure 2c. The Twisted File Small Pack Assortment (.08, .06, and .04 tapered TF).
Figure 3. The noncutting pilot tip of the TF.
TF is extremely resistant to fracture and very flexible, and has excellent cutting
efficiency. Many TF cases can be done with a single file, 2 files, or at most 3 files. It
is simple to use, has a minimal learning curve, and can be easily integrated into both
specialty and general practice (Figure 2a). TF also tracks canals very well and moves
apically without undue pressure or force. Finally, TF shows very little, if any,
tendency to screw in.
TF is available in 5 tapers (.12, .10, .08, .06, and .04) and a fixed 25-tip size. Aside
from these individual packs, TF is packaged in a Large Pack Assortment (.10, .08, and
.06) and a Small Pack Assortment (.08, .06, and .04), and is available in 23- and 27mm lengths (Figures 2b and 2c). TF has a noncutting pilot tip (Figure 3) and can be
used with a wide variety of sequences for most clinicians and anatomies.
CROWN-DOWN TF TECHNIQUE
Figure 4. Clinical case treated with a single .10 TF file.
Figure 5. Clinical case treated with 2 files, the .10 TF and .08 TF.
Figure 6. Clinical cases treated with 3 files, crown-down, .12, .10, and .08.
Crown-down technique will predominate as the most effective sequence if a singlefile technique is not preferred for the given anatomy. In the crown-down TF
technique, the files are used from larger tapers to smaller. For an average molar case,
this means that the .10 TF is inserted first, and if needed, the .08 TF and .06 TF
follow. For many cases, a single file will be needed, sometimes 2 files, and less
frequently, all 3 of these tapers (.10, .08, and .06). It is uncommon that 3 tapers of TF
would be needed for an average molar. For larger canals, the initial file in the coronal
one third would be a .12 or .10 taper. For medium canals, the initial taper in the
coronal third would be .10 or .08. For small canals, the initial taper in the coronal
third would be .08 or .06. For a multiple-file crown-down technique, the next smaller
TF taper would follow the first taper used at the orifice. The .12 TF is used more as an
orifice opener and is generally only taken down the roots below the orifice of very
large canals (eg, the palatal roots of upper molars or the distal roots of lower molars
only when it is easily accepted and the root has no significant fluting).
In a single-file technique, a single TF file can be used to enlarge the entire canal. With
passive insertion, canal preparation can be accomplished in this manner. Many wideopen and unrestricted straight canals (upper anterior teeth) can be easily enlarged with
a single .12-tapered TF file. Many medium-sized canals (bicuspids) generally can be
treated with a .10-tapered TF. Many small canals (lower anteriors) can be treated in a
single-file technique with a single .08 TF.

How does the clinician know if the TF should be used as a single file to the apex or if
the root should be enlarged crown-down? The first TF entered into the root should be
wiped free of debris, and the canal should be irrigated and recapitulated. If it can be
reinserted passively and one can make apical progress, assuming that it is an
appropriate taper for the entire root length, then the clinician can advance the single
TF file apically to reach the apex in usually an average of 3 to 4 insertions. If, for
whatever reason, the single TF does not want to advance apically (easily and
passively), the clinician should select the next smaller TF taper (Figures 4 to 6).
TF requires (as does all RNT file use) straight-line access and initially that the canal
be negotiable to a Nos. 10 to 15 hand K-file. The canal should be lubricated at all
times, ideally with sodium hypochlorite or chlorhexidine, depending on whether the
tooth is vital, necrotic, etc.
The canal should be irrigated and recapitulated after TF insertion whether the
clinician is moving crown-down or as a single file technique. Any electric motor
currently being used for RNT files (corded or cordless) can be used with TF. While
individual preferences will vary, SybronEndo recommends that TF should be run at
500 rpm. While a surgical operating microscope (Global Surgical) is not required to
use TF, using a SOM during all phases of endodontics raises the level of care
provided due to the commanding visual and tactile control that the clinician has over
the enlargement of the canal.
KEY TECHNIQUE AWARENESS TIPS
Choose the correct taper. Since TF is a single tip size system, choosing the correct
taper initially is critical for creating the desired shape of the final preparation. To
create a continuous taper, the clinician would not use a .12 taper in the coronal third
and use a .04 taper in the apical third. For the majority of molars encountered in
general practice, a .08- or .10-tapered TF would be the maximum taper used to the
apex. While these tapers might seem ex9aggerated, such exaggeration is based on
thinking in a ground file mentality. Since TF is a twisted file that has never been
machined against the grain structure, one has the capability to routinely and easily
insert such tapers to the working length (TWL).
Be aware of the position of the master cone (MC). TF cuts dentin very efficiently. TF
cuts moving apically without undue
pressure, especially in mild to moderate curvatures. In relatively straight canals, it is
essential that the clinician know when he or she is approaching the estimated or true
working length when shaping in the apical third. Such cognizance can minimize the
possibilities for apical transportation. Apical transportation with TF can be prevented
by careful observation of the apical extent of insertion and by visualizing the laser
markings and/or rubber stopper against the reference point during insertion.
TF FAQS:
How many times can I use a TF?
SybronEndo recommends single use of TF. I have used them in 3 to 5 canals.
How do I fit a cone with a TF? Are there matching master cones?
SybronEndo has introduced matching TF gutta-percha and TF paper points. A
clinician who wants to custom-fit his or her own gutta-percha cones to TF
preparations can do so. In addition, the .06 No. 20 RealSeal cones can be used as a

universal, bonded obturation cone for TF preparations. This taper and tip size cone
can be trimmed to achieve tug back in the vast majority of roots encountered.
If I see stretching of the TF file, do I have to discard it?
TF is designed to be a single-use file, which means it can be used in one canal or one
tooth, whether that tooth has one canal or 5 canals. The surest way to maximize the
functionality, efficiency, and fracture resistance of TF is to utilize it as a single-use
file. If the file shows any signs of deformation, it should be discarded.
Can TF be used in any kind of anatomy? Are there any teeth or curvatures in which
you would not use TF?
When used appropriately, TF can be used in any kind of anatomy, and the learning
curve for TF is short. The tactile control needed for TF is much the same as with
existing RNT systems. The cutting efficiency and the fracture resistance of TF will be
a revelation to clinicians. TF wants to move apically and does not require the apical
pressure to advance it that existing RNT files do. All of the above notwithstanding,
techniques might need minor modification depending on the severity of the curvature.
For example, if the curvature is extreme, after achieving straight-line access, irrigating
copiously, and recapitulating frequently, the entire canal might be prepared to the
TWL to a .04-tapered TF. Then, the whole preparation could be subsequently enlarged
to a .06-tapered TF. The final prepared taper must be balanced against the risk of
perforation, removal of only the needed dentin to facilitate irrigation, and obturation
with the achievement of a continuous taper.
How do I know if I should use multiple TF files or if a single-file technique is
indicated?
If a canal will allow apical advancement without undue pressure, TF can be inserted
as far as the file will go passively. The TF file should be withdrawn, the flutes wiped,
the canal irrigated and recapitulated, and the TF reinserted. In such a series of
insertions, irrigations, and recapitulations, with a single file the entire canal can be
shaped for many roots. If the given TF encounters undue resistance, the next smaller
taper TF can be used. For the majority of molars that will be encountered in general
practice, the combination of .10 and .08 TF will be used in tandem to reach the apex
of the given root if the clinician opts to use multiple TF files of diminishing taper. Part
of the answer to the question involves the ideal master apical taper that the clinician
seeks to achieve, giving respect to the degree of curvature that the canal possesses. As
long as the initial TF file inserted is not forced and advances passively, it can be taken
to the apex if the taper being prepared is appropriate for the given root.
Figure 7a,b. Clinical case with warm carrier-based materials that were removed with
TF.
Can I use TF for retreatment of pastes, gutta-percha, warm carrier-based devices, etc?
Yes! TF can be used to remove gutta-percha, pastes, warm carrier-based devices, etc.
Rotational speeds for such uses are increased slightly, from 900 to 1,500 rpm.
However, endodontic retreatment is primarily a specialist procedure and should
virtually always done under the SOM. Clinical judgment is called for and caution is
always advised when performing these advanced clinical functions (Figures 7a and
7b).

What is the optimal rotational speed for TF?

SybronEndo recommends a rotational speed of 500 rpm. After the clinician becomes
familiar with TF, he or she may feel comfortable utilizing enhanced rotational speeds.
What if I want to create a larger master apical diameter than a 25? How can I do that?
Larger apical diameters can be created in any way in which the clinician chooses. TF
is fully compatible with any other RNT file system desired. After choosing the desired
taper that is taken to the true working length, most clinicians will fit a cone. If the
clinician wants to create a larger master apical diameter, then the clinician can gauge
the apex and use the size determined to create a larger master apical diameter as
desired. For example, if the canal gauges to a No. 20, the final apical preparation can
be taken to a No. 35, as desired.
What if I have a tooth longer than 27 mm? How do I cope with that clinically?
To begin with, few teeth (especially treated in general practice) are longer than 27
mm. Of course, such longer roots are found occasionally and are often an indication
for referral. The simplest way to deal with this event is to reduce the occlusal
reference point as needed. This can help extend the reach of the TF as indicated.
If I were to buy a few TF files to try them out, which ones would they be?
The TF files that will be used most often are the .10 .08 and .06. These tapers will
usually be used in a single-file technique and in a 2-file tandem.
The .12 TF will be used mostly in straight and open canals such as the palatal canals
of upper molars. As an orifice opener, the .12 TF will be used primarily at the orifice
level only to allow access for the subsequent TF files, and not taken into the mid root
region unless used to the apical third in wide-open canals.
The .04 is used more for initial canal enlargement after the creation of a glide path. It
can easily negotiate even the most severe curvatures if used correctly and can create
the minimal enlargement needed to allow a subsequently larger taper (.06 or .08) to be
created to length.
I am happy with my existing rotary files. Why should I change my instrumentation?
TF is a completely new paradigm in RNT instrumentation. Without the limitations of
ground file technology (microcracks, lack of cutting efficiency, etc), R-phase
technology allows files to be used with a safety and efficiency that was never before
possible. For example, in some canals, one can often perform an enlargement of the
entire canal in 1 to 3 insertions of the single TF instrument. In other anatomies, it is
possible to shape the entire canal with 1 to 3 insertions of a .10 TF and 1 to 3
insertions of a .08 taper. This represents a real advancement because it is virtually
impossible to create, for example, .08 taper in the apical third of molar roots,
especially around a curvature with ground RNT files.

TACTILE CONTROL FOR TF

TF insertion is gentle and passive. The motion is continuous and controlled. The
motion of insertion takes approximately 2 to 3 seconds. TF is not left spinning around
a curvature; it is either being inserted or withdrawn at all times. Insertion takes place
to resistance, and then the file is withdrawn. In my hands, by the time the tactile
sensation of resistance is felt and the file is withdrawn, the flutes of 3 to 4 mm of the
file are filled with chips. The chips and debris on the flutes are removed, and the canal
irrigated and recapitulated. The same TF will be inserted again in a single-file
technique, and a smaller TF will be in-serted in a multiple-file crown-down technique.
USEFUL TF UTILIZATION TIPS
Figure 8. Multiple handpiece attachments for a cordless motor, each with a different
TF inserted. Changing out the attachments is much more efficient than changing an
individual file. Figure 9. The M4 Safety Handpiece.
TF files can be placed in multiple handpiece attachments ready for insertion into the
corded or cordless handpiece male connector (Figures 2a to 2c). The insertion of
attachments is faster and more efficient than putting individual files into the single
attachment. Attachments with the preset files should be kept in the order of larger to
smaller tapers. In this way, if they are used and put back on the dental tray in that
same order, they can be more easily delivered back into the tooth, if and when they
are needed again (Figure 8).
Blending the M4 Safety Hand-piece attachment (SybronEndo) with TF creates
efficiency. However, the clinician does not need the M4 to use TF. The M4 Safety
Handpiece is an attachment that fits onto any E-type electric motor attachment (Figure
9). The M4 can reciprocate a hand K-File/reamer in a reciprocating 30-degree
clockwise and 30-degree counterclockwise motion. Clinically, if a canal is calcified
and its negotiation by hand is difficult and time consuming, the M4 can be a
significant aid. To use the M4, a No. 6 hand K-File is placed just at, or slightly
beyond, the minor constriction. The file is left in the tooth under the rubber dam. The
M4 is attached onto the hand K-File while in the tooth and activated. With a 1- to 3mm vertical amplitude motion, the file, while attached to the M4, is moved slowly up
and down until the file is free of resistance. This enlargement usually takes
approximately 15 to 30 seconds. A No. 6 hand file used in this manner can usually
enlarge a canal to approximately a No. 8 hand K-File diameter. Similarly, a No. 8 can
often enlarge a canal to the diameter of a No. 10, etc. Once the minimal diameter of a
No. 10 hand K-File is created in the tooth, the TF is inserted into the canal in the
coronal third and enlargement begins.
CONCLUSION
A new method of canal enlargement has been introduced. The Twisted File (TF), by
virtue of a proprietary process of heating, cooling, and twisting, special surface
conditioning, and the fact that the file is not created by grinding across its grain
structure, has created a file with excellent fracture resistance and cutting efficiency.
This new technology in file f