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Endodontic Topics 2013, 29, 125–159 © 2013 John Wiley & Sons A/S.
All rights reserved Published by John Wiley & Sons Ltd

ENDODONTIC TOPICS
1601-1538

Ultrasonics in endodontics
ELLEN PARK

The power of ultrasonic vibrations has been harnessed in the field of dentistry—evolving in its use and
purpose—for just over 60 years. The first section of this review describes the evolution and various applications
of ultrasound in dentistry, and examines in detail the ultrasonic tools that have been developed for endodontic
purposes. The second section of this review describes the use of ultrasonics during specific endodontic procedures,
from access to obturation, incorporating as much as possible the most recent and relevant research available to
date.

Received 27 July 2013; accepted 1 September 2013.

Introduction: technology piezoelectric effect, then, which is the application of

and history
History of ultrasound and description
of principles
The scientific principle enabling enabling the
production of mechanical vibration in the ultrasound
frequency range is the piezoelectric effect, which was
discovered in 1880 by Pierre and Jacques Curie (1).
The term piezoelectric means “electricity by pressure,”
a word created by Wilhelm Hankel in 1881 to describe
the phenomenon of generating an electric charge from
the application of mechanical or strain energy onto
a crystalline piezoelectric material (2). Pierre and
Jacques Curie first made this discovery in Rochelle salt,
while also identifying other naturally occurring
crystals, such as quartz, tourmaline, and topaz, that
have piezoelectric capability. Other widely used
piezoelectric materials, such as piezoelectric ceramics,
fibers, and polymers, have since been developed,
making the application of piezoelectricity ubiquitous,
including sensor technology, power harvesting for
portable and wireless electronic applications, sonar,
high voltage power sources, radio and television, and
clocks (3,4).
The benefit of ultrasonic technology in practical
dentistry and endodontics occurs mostly from the
production of vibratory movement, not from
the production of electricity. The corollary of the
electrical energy to a piezoelectric material, results in
mechanical energy that is harnessed by dental ultrasonic
devices (2). The mechanical energy is transferred to
cutting tools or tips that produce microvibratory
movements in the ultrasonic frequency range. This
reverse piezoelectric effect was theoretically predicted
by Gabriel Lippmann in 1881, and then verified, again,
by the Curie brothers shortly thereafter (2). Ultrasonic
frequencies are those oscillating sound pressure waves
above the upper limit of the human hearing range,
which is approximately 20 kilohertz (kHz). The
ultrasonic frequency range often used in dentistry is
25–42 kHz; in comparison, the sonic frequency range
is 6–8 kHz (5,6). Most commercial piezoelectric dental
devices produce oscillations between 28–36 kHz.
Ultrasound in early cavity preparation
Starting in 1951, Lewis Balamuth filed a series of
patents relating to the development of a hand-
operated ultrasonic device with cutting tools that
would oscillate at a very high frequency and low
amplitude, for use in cutting tooth structure for cavity
preparations. An abrasive slurry containing particles of
aluminum oxide was flowed around the end of the
tool, which was pressed against the tooth structure to
be cut. It was the inventor’s belief that cavitation of
the liquid component of the slurry, whereby the liquid
would rupture with tremendous force, caused the

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abrasive particles in the slurry to be continuously
driven against the tooth structure. This action was
thought to be primarily responsible for the cutting
action (7). The ultrasonic vibrations in this particular
dental device were produced by magnetostriction,
as opposed to piezoelectricity. Magnetostriction is
another way in which ultrasonic vibrations are created.
The principle of magnetostriction was discovered by
James Joule in 1847, who showed that an iron rod
could increase in length when exposed to a magnetic
field (8). Magnetostrictive units operate between
18–45 kHz, converting electromagnetic energy into
mechanical oscillation when an alternating magnetic
field is applied to a stack of metal strips. The metal
strips are made out of a ferromagnetic material that
changes their physical dimension lengthwise, causing
the ultrasonic tip to vibrate (9–11).
The initial response to ultrasonic cavity preparation
was positive, with studies of that time reporting
the benefits of an efficient, noiseless, heatless, and
vibrationless mode of tooth preparation, even without
the need for local anaesthesia (12). The pulp response
to ultrasonic cavity preparation was favorable and thus
deemed safe for use (13). Although promising, the
disadvantages included limitations with respect to
visibility, wear of the working tips, a technique-
sensitive method, and expense in acquiring the device.
Most importantly, the perceived efficiency of
ultrasonic cavity preparation could not surpass the
practicality of high-speed rotary cutting (9,14).
Despite the versatility and advancement, in recent
years, of laser and air abrasion tools, the high-speed
handpiece continues to be the primary method of
conventional cavity preparation, and is unlikely to be
replaced by any other technology (15).
Current trends in ultrasonic
cavity preparation
It is interesting to note that, within the last decade,
interest in ultrasonic cavity preparation has
experienced a small resurgence, possibly having to do
with improved and modified ultrasonic devices and
tips and its heavily adopted use in endodontics,
periodontics, and oral surgery.
The development of diamond ultrasonic tips in the
late 1990s manufactured using a method called
chemical vapor deposition (CVD) resulted in high
adherence of the abrading diamond material onto the
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metallic surface, thus improving the performance of
existing ultrasonic tips for cavity preparation. Today,
this is a promising alternative to the use of high-speed
rotary handpieces in cavity preparation, as well as the
removal of composite and amalgam materials (16).
Several studies have reported the advantages of using
CVD tips, such as tip durability, improved access, and
ultraconservative caries removal (17). The reduction
in noise production has also been reported as
beneficial in pediatric dentistry, where the sound of a
high-speed turbine can be unpleasant for young
patients (18). However, ultrasonic cavity preparation
with CVD diamond ultrasonic tips, although equally
effective in cutting and less invasive, can still be 4 to
8 times slower than traditional rotary diamond
bur preparation, with one study also reporting
a significantly higher rate of microleakage after
restorative procedures due to the production of a
dentin surface less favorable for adhesion systems
(19–22). A different study reports no difference in
tensile bond strength after adhesive procedures
between the two modes of tooth preparation (23). At
the present time, the results of studies comparing the
topography of tooth tissue after cavity preparation or
prosthodontic margin refinement with ultrasonic tips
or high-speed rotary instruments are inconclusive;
some report a difference in topography with more
surface roughness after ultrasonic preparation (24,25),
while others report smoother margins and fewer
striae with the use of ultrasonics (26,27). Although
ultrasonic cavity preparation has many advantages, it
likely will not affect current clinicians’ primary reliance
upon high-speed handpieces.
Ultrasound in periodontal therapy
The most common use of ultrasonic devices in
dentistry has been for the removal of plaque and
calculus for periodontal therapy, a discovery that is
attributed to Zinner, who reported on the use of
ultrasonics without the use of an abrasive (28). Hard
accretions on the tooth surface are removed primarily
by the physical action of the oscillating tip;
incorporation of an abrasive would damage the tooth
surface. Since the introduction of the magnetostrictive
Cavitron prophylaxis ultrasonic device by Dentsply in
the late 1950s, this particular device has been the basis
for the majority of dental-related ultrasonic research in
the years following its introduction to clinical practice

(9). Since then, many other ultrasonic devices have
been manufactured by various companies. Both
magnetostrictive and piezoelectric ultrasonic devices
are used in scaling, but it is inconclusive whether one
device is preferable over the other for scaling. One
concern is the resulting smoothness of the tooth
surface; one study shows that a piezoelectric scaler
leaves a statistically significantly smoother tooth
surface than the magnetostrictive device when using
the same lateral pressure (6). In contrast, another
study reports the piezoelectric device to be more
efficient in removing calculus, while leaving the root
surfaces rougher than magnetostrictive devices (29).
The results of a consensus position statement is that
scaling and calculus removal using hand instruments,
sonic, or ultrasonic devices produce similar results, and
it is undecided whether surface roughness affects
healing of the periodontium or which method of
removal produces the most surface roughness (30).
Ultrasound in endodontics
The application of ultrasonics to endodontics is
credited to Richman, who first wrote about its
application to root canal therapy and root resection in
1957 (31). The research literature from the 1950s
reflects a heavy emphasis on the use of ultrasonics in
cavity preparation and scaling and calculus removal.
The research during the next two decades sought to
further develop ultrasonics in periodontics, and also
sought to find new applications for ultrasonics in
dentistry. During the 1960s, researchers investigated
the use of ultrasonics for cleaning instruments,
removing stains from acrylic resin dentures, and in
precision metal casting for dental purposes (32–35).
During the 1970s, in addition to examining the effect
of ultrasonic tools on the tooth surface during
periodontal therapy (36,37), ultrasonic technology
was applied to temporomandibular joint dysfunction
therapy (38) and used to measure translatory
movements of the condyle during motion (39). In
1976, a study by Martin on the use of ultrasonics
to increase the bactericidal efficiency of irrigation
during root canal therapy was published, using a
magnetostrictive ultrasonic scaler adapted to produce
oscillatory motions in an endodontic file (40). Martin
found that applying ultrasonics to a bactericidal agent
resulted in more efficient killing of bacteria (41). This
presumably followed studies in other applied science
Ultrasonics in endodontics
disciplines that investigated the use of ultrasonics to
enhance the inactivation of bacteria (42,43). In the
same year, a different study reporting on what is
presumed to be the first use of a modified ultrasonic
tip for a retropreparation during an apicoectomy was
published (44). Both studies, almost 20 years after
Richman’s inceptive paper, were harbingers of two
important techniques used today, garnering in the
age of “endosonics,” a term coined by Martin &
Cunningham (45,46). Into the 1980s, research
momentum increased for looking at the synergistic
way in which ultrasonic oscillations were able to
produce cleaner root canals during irrigation and the
effect of using ultrasonically activated files on dentin to
directly instrument root canals (47,48). Although
other instrumentation methods, most famously
nickel–titanium rotary instrumentation, have largely
rendered ultrasonic root canal instrumentation
ineffective, the role of ultrasonics in the agitation and
activation of irrigants during the chemical cleaning
phase of endodontics has enjoyed a revival in
popularity and importance. This is reflected in the
research literature of the past decade and in the
adoption of the working principles in practical
techniques by clinicians.
During the 1990s, the focus turned to the use
and possible consequences of ultrasonic root-end
preparations during apicoectomy after the commercial
introduction of the first retrotips designed by Dr. Gary
Carr (49). Although some early endodontic studies
have used magnetostrictively powered ultrasonic
devices, the piezoelectrically powered device has
become the preferred choice among clinicians for
endodontic work. Firstly, the magnetostrictive devices
generate more heat than piezoelectric devices, which is
less desirable when cutting bone and structures near
bone (50). Secondly, the elliptical motion that has
been attributed to magnetostrictive devices is not
considered ideal for endodontic use, although the
exact nature of tip motion in piezoelectric devices has
recently been called into question (51). What the
piezoelectric device and the many tip designs that have
become available since the 1990s have allowed
clinicians to do is remove dentin or other dental
materials in a very controlled and precise manner,
using tips that are often approximately the same size as
root canal dimensions or smaller. Other tips are
designed to deliver vibrational energy in a focused
manner, without the intention to cut tooth structure.
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These capabilities have resulted in a wide range of
indications for use during procedures such as access,
re-treatment, and apicoectomy.
It is interesting to consider that only 20 years ago,
the rationale for the use of ultrasonics in endodontics
was considered controversial (52), as it is now an
integral tool during most tasks and challenges of root
canal therapy.
Ultrasound in oral surgery
When ultrasonic microvibrations are applied at
frequencies between 25 and 29 kHz, the tip is able to
selectively cut mineralized tissues without permanently
damaging soft tissues (53). When coupled with
specially designed tips, a great measure of safety and
precision cutting of bone is possible in anatomical
areas with important soft tissue structures such as
nerve tissue. The piezosurgery device for oral surgery
is three times more powerful than the typical dental
ultrasonic unit and uses modulated frequencies,
allowing it to cut through highly mineralized tissues
(54).
The development of piezoelectric bone surgery in
1988 is credited to Dr. Tomaso Vercellotti, and has
been adopted in many oral surgery procedures, such as
sinus lifting, bone grafting, orthognathic surgeries,
and craniomaxillofacial surgeries (53,55). Clinicians
have also reported little residual debris, less bleeding in
the surgical site attributed to the effects of cavitation,
and minimal trauma in comparison to the use of
traditional bone-cutting instruments (56). The time
required for piezosurgery is considered comparable,
although longer, to the use of conventional tools, and
only light forces are required for optimal cutting
depths (57–59). The postoperative healing is
considered to be excellent, with patients experiencing
less stress than during conventional surgery (57,60).
Medical surgical procedures requiring precision
during osteotomy or osteoplasty in the vicinity of vital
soft tissue structures (such as in neurosurgery or
orthopaedic surgery) are quickly adopting this
technology as well.
Biophysical effects of ultrasound
The physical effects created by the production of
ultrasound are oscillations, heat, cavitational activity,
acoustic microstreaming, and radiation (11). The
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relevant physical effects, such as oscillations, cavitation,
and acoustic microstreaming, are mostly beneficial
to endodontic procedures, but some effects, such
as the production of heat and the emission of
electromagnetic energy, require precaution to be taken
in certain clinical circumstances.
Acoustic streaming
As mentioned in the previous section, piezoelectric
ultrasonic devices are now widely used in endodontics,
resulting in a handpiece that is able to deliver
oscillatory movement in the ultrasonic frequency
range with wider oscillation amplitudes than
magnetostrictive devices (61). When ultrasonic tips are
used in the handpiece, the mechanical oscillation
produced at the tip is used to cut biological tissues or
dental materials. When endodontic files are used in the
handpiece, the files oscillate along the longitudinal axis
of the instrument, with maximal amplitude occurring
at the antinodes and minimal oscillation at the nodes
(40). The file oscillations are primarily responsible for
the production of acoustic streaming, which is the
movement of fluid in a vortex-like motion around the
file when pressure waves are projected through it (62).
Acoustic streaming may also be associated with the
occurrence of cavitation, which will be discussed
shortly (63). Regular streaming patterns have been
visualized even in tight geometries, such as a root canal
(64), and can help to replenish spent irrigant in the
apical region of a root canal (62). However, the
streaming patterns can change, especially if a file is
loaded or disturbed near an antinode (64).
Cavitation
Cavitation refers to the oscillatory motions of gas-
filled bubbles in an acoustic field, bubbles that are
powered by energy from the ultrasonic field (40). The
microscopic bubbles are formed and then collapse
and explode, resulting in localized areas of pressure
and heat production (65). This transient type of
cavitational activity has been shown to occur around
the tips of ultrasonic scalers (5). When a tapered file is
used to transmit ultrasonic oscillations, theoretically a
displacement amplitude of greater than 135 μm is
required to produce cavitation (66). When the
collapse of these microscopic bubbles occurs near a
surface, microjets are formed that can use shear

hydrodynamic forces to aid in the removal of adherent
matter, an effect that is reported to have an affect
0.5 mm from the ultrasonic tip (65,67). The
significance and presence of transient cavitation during
the use of dental ultrasonic devices is uncertain. It has
been reported that no cavitation is present during the
oscillation of several sizes of endodontic files at various
power settings appropriate for clinical use (63). More
recent studies have shown the presence of cavitation
at the second antinode or the body of a file, with
no cavitational activity at the tip during unloaded
conditions (68). A different study reports cavitation
activity at the tip during unloaded conditions under
high power settings (69). Some cavitation has been
seen at the tip during loaded conditions (65). It is
possible that the presence of cavitation may be related
to the power setting used and a threshold amplitude of
movement of 135 μm (70,71). The contribution and
reliable production of cavitation during clinical
endodontic procedures is a debatable issue.
Heat
Thermal imaging has been used to show that
piezoelectric ultrasonic devices, as well as
magnetostrictive ultrasonic units, produce heat when
in contact with tooth structure or dental materials due
to friction (72). Ultrasonic vibration of a metal post
under dry conditions can produce significant heat
transfer to surrounding tooth structures in as little as
20 s; it is advised to intermittently cool the post with
water or air (73). The general heating effect can be
minimized by using low and medium power settings,
and also light contact, but water should be used to
cool the tooth structure (or the air-flow function
in newer ultrasonic models), depending on the
procedure (74). Ultrasonic activation is also able to
increase the temperature of the surrounding irrigant in
a root canal up to 10 degrees Celsius (75). It has been
shown that heating sodium hypochlorite greatly
increases tissue dissolution (76).
Aerosol
When an ultrasonic device is used with water coolant,
an aerosol is produced that can contain
microorganisms and even blood contamination
(77,78). These aerosols can remain airborne for some
time. The use of an extraoral high-volume evacuation
Ultrasonics in endodontics
is able to significantly reduce the aerosols produced
(78,79). One study, using a high-volume evacuation
and conventional dental suction, found limited
microbial contamination when a piezoelectric
ultrasonic scaler was used for hygiene therapy (80).
The use of a preprocedural mouthrinse of 0.12%
chlorhexidine or 0.05% cetylpyridinium chloride has
also been shown to significantly reduce the microbial
content of dental aerosols (81,82). Aerosol reduction
measures appropriate to the dental procedure should
be taken when using an ultrasonic device.
Pacemakers
The current evidence on the effect of ultrasonic dental
equipment on cardiovascular implantable electronic
devices (pacemakers) is inconclusive. It has been
shown in the past that dental equipment capable of
applying an electric current to a patient could
potentially interfere with a pacemaker (83), including
magnetostrictive ultrasonic scalers (84). The few
studies that have examined the effect of piezoelectric
ultrasonic units on pacemakers have found no
interference to date (77). Current guidelines
recommend the avoidance of magnetostrictive devices
on those patients with pacemakers, whereas the use of
piezoelectric devices does not appear to affect
pacemakers (85). More research is recommended and
clinicians should be thorough in documenting the
type of pacemaker device, including serial number and
mode of operation, in the patient chart (85).
Current endodontic
ultrasonic machines
Technology
The first piezoelectric ultrasonic device for dentistry
was developed in 1979 by the Satelec company (86);
such a device generally consists of the main body that
contains the ultrasound generator, a foot pedal, and a
handpiece. While the operating frequency is generally
fixed and not changeable by the clinician, the main
body contains a power dial to control the power
setting and thus the power output; increasing the
power setting should theoretically increase the
amplitude of the oscillation (67). A piezoelectric
material is contained in the handpiece that oscillates at
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a frequency of 24–42 kHz in the presence of an
electromagnetic field (5). In some ultrasonic
generators, the tip is pushed to the farthest extent of
the amplitude, and with the opposite action being a
recoil action. Other more recent ultrasonic generators
control both the push and pull motion, resulting in
better control (86). The oscillations are transmitted to
an ultrasonic tip, some of which are designed to also
deliver water or air, depending on the purpose of use.
The flow rate of water delivery can be adjusted on
most ultrasonic units.
There has been much interest in the type of
oscillation patterns produced by magnetostrictive or
piezoelectric devices. The movement of the tip can be
characterized by measuring its amplitude and by
describing its pattern of motion. It had been
previously thought that piezoelectric devices produced
only linear vibrations of an ultrasonic tip. The most
current research indicates that piezoelectrically
powered tips result in elliptical patterns of movement,
ranging from near-linear motions to circular motions,
both under unloaded and loaded conditions (87).
Even during unloaded tip conditions, the elliptical
axes of the motion was subject to change (87). What
has been determined to be a significant factor in the tip
motion and vibration amplitude is the actual geometry
of the tip itself, with long and slim tips operated at
high power producing greater elliptical patterns than
short and broad tips operated at low power settings
(51). Other factors such as the power setting used,
lateral force, water flow, and tip angulation are known
to affect vibration motion and amplitude as well
(88,89). Even the tightness with which a tip is screwed
into the handpiece with the proper wrench may affect
the motion and amplitude (51). Some modern
ultrasonic devices, however, incorporate a feedback
mechanism in the ultrasound generator that provides
more power to the tip when the tip is in contact with
a surface (86). The result is that the longitudinal
component of oscillation is unchanged in unloaded
and loaded situations, or even increased during loaded
conditions (87). In this way, the efficiency of the tip is
relatively unchanged.
Power
A recent study compared the cutting efficiency of two
ultrasonic units, using each unit at a mid-range and
high power level, and reported one unit to be able to
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remove 202% more dentin at comparable power levels
(90). There is variability in the power output of
different ultrasonic units such that the linear/
numerical scale of the power dial is not an accurate
estimation of power outout, and is not comparable
from machine to machine, even within the same
manufacturer (70,91,92). The displacement
amplitude of ultrasonic tips has been reported to
increase linearly with increasing power settings in one
study (91), and a different study has also shown that
tips operated at high power were 240% more effective
than the same tips operated at mid-level power (90).
However, a more recent paper using scanning laser
vibrometry to evaluate the vibration characteristics has
shown that there is little consistency in power output
and no linear increase in tip amplitude with increasing
power settings (93). In fact, the ultrasound generator,
handpiece, and power were all significant variables,
with significant variability between generators and
handpieces of the same model. It is unknown at the
present time whether this is a generalizable finding to
all piezoelectric dental units; ultrasonic devices with
improved features with respect to control of power
and amplitude have recently been developed and thus
more research is indicated. As such, it is recommended
to select a low setting initially, and increase the power
as needed in the clinical setting for any tip selected for
use (93).
Commercial ultrasonic devices
There are many commercial piezoelectric ultrasonic
dental devices available from companies such as
Sybron Dental Specialties, Obtura Spartan, Osada
Inc., EMS, Dentsply Tulsa Dental Specialties, Acteon,
and Vista Dental Products. Many such devices are
versatile and can be used for endodontic, periodontal,
general dentistry, and hygiene procedures with the
correct tips, irrigation, and power level. The ProUltra
Piezo by Dentsply Tulsa is a popular device (Fig. 1),
and is designed to be used with the ProUltra or
Satelec handpiece (the Satelec handpiece with LED
components). The ProUltra endodontic tips or Satelec
ultrasonic tips are compatible with these handpieces,
but compatibility should be checked when using
components from different manufacturers. Hygiene
and periodontal tips can also be used with the
ProUltra Piezo device, although the use of water is
recommended (as for other ultrasonic devices) during

Fig. 1. ProUltra Piezo ultrasonic device by Dentsply
Tulsa.
such procedures. The use of water can be omitted for
certain endodontic applications, such as the removal
of obstructions or locating hidden canals, but the
potential for heat transfer should be recognized during
procedures such as post removal or retropreparation,
and appropriate cooling measures used. The frequency
range generated by the ProUltra Piezo device is
28–36 kHz, which is similar to other ultrasonic
devices. The ProUltra Piezo features several
improvements compared to older generations of
ultrasonic devices. These improvements are grouped
under the term SmartPower® technology and feature
bi-directional power and control in both forward and
reverse oscillation directions, allowing the tip to stay
centered within a precise operating parameter. Older
ultrasonic devices produce the bi-directional
movement by pushing the tip and allowing the tip to
recoil on its own. The ProUltra Piezo device maintains
the desired power without adjustment of the dial
setting when the tip is loaded during use, and is also
able to recognize the intended working frequency of a
particular tip, operating the tip at that optimal
frequency. The tips are tightened by a wrench as a
tight fit is required, but one must be cautious not to
overtighten the tip, as there is no stop point and
Ultrasonics in endodontics
damage of the handpiece may occur. A water flow rate
of 0–90 mL/min is possible, and adjustable for use
with those ultrasonic tips with a water port. The
several technological improvements featured in the
ProUltra Piezo are identical to the Newtron Cruise
Control® technology incorporated into the P5 series of
ultrasonics by Acteon. The Newtron line also offers a
handpiece with an LED light option, which may be
helpful if the operator does not have a strong light
source or is not using a surgical microscope. The
Newtron line also offers variations of their ultrasonic
devices, featuring an option for a self-contained
irrigation unit, and an option for an “air-active”
feature which allows filtered air to be channeled to the
tip at low pressure to remove debris.
Current endodontic ultrasonic tips
and attachments
A great variety of ultrasonic tips are commercially
available for endodontic, periodontal, surgical, and
general practice uses. The tips manufactured by
various companies are often able to be used on
different piezoelectric ultrasonic devices, but one must
check that the thread pattern on the unit and the tip
is compatible. Two different thread patterns, an
E-thread and an S-thread, are currently used. The tips
are also manufactured from a range of metal alloys,
such as stainless-steel and titanium alloys, and can be
coated with an abrasive such as diamond or zirconium
nitride in order to increase the cutting efficiency of the
tip. Many of the tips incorporate a built-in water port
so that debris can be washed away and cooling can take
place if desired. Almost every ultrasonic tip for
endodontic use incorporates a contra-angle bend that
allows the clinician to have a virtually unobstructed
view into the working area, and is most easily used
with the aid of a surgical operating microscope.
Surgical endodontic ultrasonic tips incorporate a
second bend placed closer to the end of the tip in
order to allow parallel access to the root canal when
creating retropreparations. As a result of the variety
of tips available, there is an appropriate tip design
for virtually every step of endodontic treatment,
from access to obturation, each to be used in the
recommended power setting range. Clinicians are able
to address teeth with hidden and calcified canals, and
those teeth with obstructions such as pulp stones,
posts, pastes, and separated instruments. Thus,
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clinicians are able to provide orthograde root canal
treatment for teeth that would have otherwise
had only apical surgery or extraction as treatment
options. Furthermore, when apical surgery is
required, retropreparations can be done in roots
around challenging anatomical configurations in a
conservative and precise manner. Clinicians should
note that the use of ultrasonic tips around porcelain
restorations can cause fracture of the porcelain
material and great caution must be exercised to avoid
direct contact. The following represents a description
of a selection of commercially available endodontic
ultrasonic tips.
Access refinement and apical
microsurgery tips
The ProUltra Endo Tips are numbered from 1
through 8, and are designed to address most
intracoronal and intracanal procedures (Fig. 2). These
were designed by Dr. Clifford Ruddle. ProUltra Endo
Tips #1 through #5 are made of stainless-steel and are
zirconium nitride-coated instruments for increased
efficiency in cutting (Fig. 2). ProUltra Endo #1
(17 mm) and #2 (17 mm) can be used from medium
(a)
(b)
Fig. 2. (a) ProUltra Endo Tips 1–8 by Dentsply Tulsa.
(b) Zirconium nitride coating on a ProUltra Endo-2
ultrasonic tip.
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to high power, and feature a wider tip and design
features suited to coronal disassembly, post removal,
and the removal of larger pulp stones. ProUltra Endo
#3 (17 mm), #4 (19 mm), and #5 (24 mm) are used
from low to medium power, and feature increasingly
longer and finer tips, suited to searching for hidden
canals, troughing fine fins and narrow isthmuses, and
removing separated instruments within the root canal.
ProUltra Endo Tips #6, #7, and #8 (20 mm, 24 mm,
and 27 mm, respectively) are made from a titanium
alloy and are used in the lower power range only. Due
to the titanium alloy construction, these end-cutting
tips have inherent flexibility and are mainly used for
apical obstructions. The ProUltra Endo Tips do not
have a water port, as much of the intended use
requires careful visualization; water is used instead
intermittently to wash away debris or for its cooling
effects. The CPR line of tips from Obtura Spartan, also
numbered from #1 to #8, are of similar design but are
coated with diamond grit and have a water port.
Specialized tips designed specifically for the vibration
of posts, such as the VT tip by SybronEndo or the
Vibrapost by B&L Biotech, feature a wide and blunt
end designed to be placed, at maximum power, against
a metal post. The ProUltra Endo #1 is often used to
vibrate posts as well.
The ProUltra Sine instruments are a set of six access
refinement tips designed by Dr. Clifford Ruddle. They
are coated with a diamond grit for increased efficiency
during cutting procedures. Although there is some
similarity in tip design to the range of ProUltra Endo
Tips, this range also features small and large ball and
football-shaped tips which are able to add precision
and control to those procedures that would otherwise
be performed with conventional carbide burs, such as
refining axial walls, removing peripheral dentin,
disassembling coronal restorations, and troughing for
hidden canals. They are used on low power settings
and have an optional water port. The BUC tips from
Obtura Spartan are also a series of six access
refinement tips, but do not feature a ball or football
end. The range of six BUC tips feature a rounded tip,
a flat disk-like tip for planing smooth pulp chamber
floors, and a pointed, active tip for apical cutting.
These too are available in small and larger diameter
sizes. They are diamond-coated and contain a water
port. The BUC-1 tip has been shown in several studies
to have a high dentin cutting efficiency in comparison
to several other tip designs (94,95).
 Ultrasonics in endodontics

Fig. 3. KiS microsurgical tips by Obtura Spartan.

The ProUltra Surgical Endo Tips are a set of six

instruments made from stainless-steel coated with
zirconium nitride, like the ProUltra Endo Tips.
(a)
However, the surgical tips have a water port, placed
near the tip for better water delivery. When used
during microsurgery, the various double angles allow
specific tips to be used in certain quadrants of the
mouth, and to reach difficult areas. The tip allows
a 3 mm retropreparation to be made. The KiS
microsurgical tips by Obtura Spartan are a similar set
of ten tips (Fig. 3). These tips are also double-angled,
feature a water port, have a 3-mm cutting surface and
0.5-mm tip diameter, but are coated with diamond
grit. The additional tips include those with a 2-mm (b)
and 4-mm cutting surface, and a 0.7-mm tip diameter.
The BK-3 tips from SybronEndo feature a Fig. 4. (a) The BL range of ultrasonic tips by B&L
microsurgical tip with three angled bends, providing Biotech. (b) 100 μm microprojections on the BL-1
access and visibility. The CT Tips, UT Tips, and SJ ultrasonic tip by B&L Biotech.
Tips from SybronEndo each address larger, moderate,
and very fine retropreparations, respectively. Designed
by Dr. Gary Carr, they are made of stainless-steel, are suited for the bulk removal of dentin, while those tips
uncoated, and feature a water port. Several of these with 50 μm microprojections are suited for those
tips are also available in a diamond-coated version. procedures requiring more precision. Also unique to
the microsurgical series is the ability of the clinician to
create a custom bend in the tip, using a specialized
Microprojection tips
bending jig with five position depths. This allows the
A new innovation in ultrasonic tip surface texture is creation of a tip with the desired angle between
the creation of microprojections on the tip body 3–7 mm in length. A recent study has shown that
instead of zirconium nitride or diamond grit coatings. the BUC-1 tip and the BL-2 tip have similar dentin
The BL tip line from B&L Biotech features a series removal efficiencies when operated at the same
of six stainless-steel endodontic tips (Fig. 4a) and a power level; however, the BUC-1 tip demonstrated
series of twelve microsurgical tips in the JETip range. greater efficiency when both were operated at the
The microprojections are integrated onto the tip manufacturer’s recommended settings (96). Linear
(except BL 6, which features a pointed tip without microgrooves, as opposed to microprojections, have
microprojections) (Fig. 4b), and thus are more also been milled into a shank for another new
resilient to wear, unlike the abrasive particles, which ultrasonic tip design in the START-X series of tips
can be lost. The microprojections are 100 μm and (Dentsply Maillefer) but these tips have been shown to

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have less efficacy than the BUC-1 tip when used at the
recommended settings (96).
Efficiency
There are only a limited number of studies, each with
different methodology, examining the conditions
under which an ultrasonic tip should be used in order
to optimize cutting efficiency and safety. The studies
to date show that optimal and safe use is dependent
upon multiple factors, such as the ultrasonic unit itself,
the power setting, and the type of tips used in a
particular study (90). Surface coatings on ultrasonic
tips are intended to increase efficiency and durability;
diamond-coated tips have been shown to require less
time than stainless-steel tips or zirconium nitride tips
to cut similar preparations (97–99), and other studies
have shown zirconium nitride-coated tips to perform
similarly to uncoated stainless-steel tips (97,99).
The recently introduced JETip ultrasonic tips with
microprojections have been shown to perform
similarly to diamond-coated tips with respect to time
of preparation, with no loss of microprojections from
the tip surface; the diamond-coated tips were shown
to have lost diamond particles from the abrading
surface (100). It is uncertain whether the loss of
diamond particles or the zirconium nitride coating
contributes significantly to the loss of cutting
effectiveness. One study applying an axial load only to
one particular diamond-coated ultrasonic tip found a
significant decrease in efficiency after 10 min of use,
but no further significant decrease up to 30 min of use
(95). A recent study has shown no significant decrease
in efficiency of cutting with the same diamond-coated
ultrasonic tip up to 190 min of use, using both an axial
force and a linear movement in order to more closely
simulate clinical practice applications (101). The
manner of use of an ultrasonic tip may influence its
efficacy. While no study has identified a single
ultrasonic tip with consistently greater cutting
efficiency than all other tips, the BUC-1 tip has been
shown in a few studies to have particular durability and
efficiency, possibly attributed to its tip design and
dimensions, but not necessarily factors such as the
surface area available for cutting and the size or
coarseness of the diamond grit particles (94,101,102).
A recent comparison of pointed ultrasonic tips using
both an axial force and linear movement found that a
diamond-coated tip removed significantly more dentin
134
than a zirconium nitride-coated tip and tips without a
surface coating (103). It is difficult to make definitive
conclusions regarding tip efficiency from the available
research due to the limited number of studies, the
differing methodologies of efficiency assessment, and
the use of different tips and ultrasonic devices.
Guidelines for use
It is recommended that ultrasonic tips be used with
a light touch and be kept moving during use, as
an excessive force can significantly reduce the
displacement amplitude of the tip (58,104). Studies
have used a range of different contact loads, from
15–200 g of force (94,97,102,104), but a recent study
has determined that the average trained endodontist
uses 15 g of downward force during ultrasonic
instrumentation (102). Excessive forces or use of the
tip in extremely narrow canals can also cause the
ultrasonic tip to stall, in which case contact with
the material being cut should be momentarily broken
in order to allow the oscillations to re-establish
themselves through the tip (105). The ultrasonic tips
should also be used at the recommended power
settings. Due to the inherent variation of ultrasonic
devices themselves, the lowest power setting in the
recommended range should be used, and increased as
needed for a given procedure. Increasing the power
setting increases the cutting efficiency of the ultrasonic
tip (90,94). However, the use of inappropriately high
power settings can result in breakage of a tip in as little
as 10 s (106). In one study, when a variety of
ultrasonic tips were placed under 100 g of loading
force and operated at maximum power, three out
of ten tips broke 2–3 mm from the tip end with
between 10 s and under 3 min of use (106). Thinner
tip designs and the incorporation of multiple bends or
excessive angulations can predispose a tip to breakage
(90,105,106).
One final concern in the safe use of ultrasonic tips is
the generation and transmission of heat to the
supporting dental structures. The production of heat
is not necessarily a terrible consequence and can be
harnessed for a beneficial purpose, such as to increase
the temperature of irrigants during ultrasonically
activated irrigation (76,107). However, it has been
shown that a temperature rise in the supporting bone
beyond 47°C for a certain period of time can produce
irreversible damage (108). Significant increases in

temperature have been detected in the post and tooth
structure during the application of ultrasonic energy to
metal posts when no cooling measures are used (109),
or during the removal of fractured endodontic files
(110). Again, the resultant temperature rise is a
multifactorial process depending upon root canal wall
thickness (according to certain studies), tip design,
power setting, and time of use (111). Intermittent use
of the ultrasonic, with copious air or water coolant, has
been shown to be effective in reducing the potential
for serious heat-related injury to the periodontal
tissues (73).
Current endodontic
irrigation attachments
Effective irrigation has enjoyed renewed importance in
the chemomechanical process of root canal shaping
and disinfection. The acknowledgement of the
inability of mechanical rotary files to debride
approximately 40% or more of a root canal surface,
especially in complex root canal systems, has
emphasized the need for irrigants to come into contact
with the entire root canal (112,113). The effect of
ultrasonic agitation or activation of root canal irrigants
by acoustic microstreaming has been shown to have
an enhanced effect on their properties (76,114).
Ultrasonic activation allows irrigants to penetrate root
canal complexities such as lateral canals with greater
efficacy than conventional irrigation methods, and also
to remove significantly more debris from canals and
isthmuses (115–118).
Ultrasonic file adaptor
Ultrasonic activation of irrigants in a root canal can be
achieved by using an ultrasonic file adaptor that will
accept stainless-steel or nickel–titanium files, from ISO
sizes 15–40. Ultrasonic file adaptors are manufactured
by several dental companies and securely hold a
smooth shank end of a file in the chuck, which is
tightened by using a wrench to turn the nut. A file can
be removed from its handle to be placed into the
ultrasonic file adaptor, or the files can simply be
purchased without a handle attached. The use of
files with a non-end cutting tip, such as the Irrisafe
files (Acteon), is recommended in order to avoid
unfavorable alteration of the apical anatomy. Irrisafe
files are parallel stainless-steel files. The file is placed to
Ultrasonics in endodontics
the apical third or the full working length in a root
canal filled with irrigant and activated in the mid-range
power settings. It is not clear exactly how much
activation time is required to make a positive clinical
impact resulting in better healing, but several studies
have shown that 1 min of activation has resulted in
significantly cleaner canals or better penetration of
irrigant into lateral canals (116,119). Microstreaming
and the ability to create shear stresses are directly
related to the square of the displacement amplitude of
the file, while cavitation, as previously mentioned, has
been shown to occur under a specific set of conditions,
such as when a file oscillates freely with a vibration
amplitude greater than 135 μm at high power levels
(66). A recent study of file oscillations using files of
various sizes and lengths in a root canal has shown that
the maximum amplitude of file displacement was
22 μm (120). In addition, increasing the power setting
actually resulted in reduced displacement amplitudes
for certain files. Such studies will help to determine
optimal conditions and settings for oscillating files and
determine whether cavitation can indeed be created in
root canals.
Ultrasonic irrigation systems
Recently, two ultrasonic irrigation needles have been
available in the commercial market that have the
additional feature of delivering irrigant during use
either by a hand-held syringe or a peristaltic pump.
They have been found to be at least as effective or
more effective than other irrigation methods
(116,121). One such needle, the ProUltra®
PiezoFlow™ Ultrasonic Irrigation Needle, is a
25-gauge flat open-ended needle made from stainless-
steel that is tightened into the ultrasonic handpiece
with a wrench and used in the mid-range power
setting in fully instrumented canals. A syringe or other
irrigation source is attached to the Luer-lock
connection on the ultrasonic needle through which
irrigant is delivered. The VPro™ Stream Clean
Ultrasonic Irrigation System (Vista) is a similar system
except that the ultrasonic irrigation needle is a
30-gauge flat open-ended needle that is constructed
from nickel–titanium. Much caution needs to be
exercised when using an irrigation needle with a flat
open-ended needle; the apical pressures created with a
flat open-ended needle can be several-fold higher at
irrigation flow rates exceeding 4 mL/min than when
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closed-ended side-vented needles are used (122).
When assessing extrusion of sodium hypochlorite
beyond the apex in an in vitro study, a continuous
ultrasonic needle using a flow rate of 10 mL/min was
found to have the highest risk for extrusion in
comparison to using a side-vented needle, negative
pressure irrigation, and passive ultrasonic irrigation
(123). This effect was particularly marked when the
continuous ultrasonic needle was operated closer than
5 mm from the root apex. Thus, great care should be
taken if using this device in teeth with open apices
and/or perforations, and binding of the needle tip
should be avoided.
Applications in endodontics
Access
Many general endodontic textbooks advocate using
various sizes of round carbide burs to create an access
preparation in teeth, often citing the sensation of
“falling” through the pulp chamber roof as an
indication of achieving access to the pulp tissue.
Clinical reality presents us with teeth where visibility is
limited and the location of the canals can be difficult,
with impediments such as access preparations through
crowns, pulp stones, and secondary and tertiary dentin
deposition. In such cases, the sensation of falling
through the pulp chamber roof does not apply and
predisposes the clinician to iatrogenic errors such as
perforation or severe gouging of the dentin walls and
floor.
Effect on porcelain materials
Ultrasonic tips are inefficient for the creation of the
initial access outline and bulk of dentin or dental
material removal, and they should not be placed in
direct contact with porcelain crowns and facings.
Although specialized ultrasonic tips can be used
with ceramics, for example during the ultrasonic
cementation of porcelain restorations (124), the brittle
nature of ceramic materials—even recently developed
ceramic materials—means that contact with ultrasonic
tips can cause ceramics to fracture and even become
dislodged (125). Thus, traditional high-speed burs are
used to create the majority of the endodontic access.
Diamond burs are used to cut through ceramic crowns
or the ceramic portion of porcelain–metal crowns as
136
they are thought to create fewer craze lines or
chipping, and less frequently cause fracture of
porcelain in comparison to carbide burs (126). In
certain studies, diamond burs and carbide burs have
caused porcelain damage in equal measure, and air
abrasion with aluminum oxide particles has been
touted as a possible way to provide access through
porcelain without the creation of chipping,
microcracks, or catastrophic failure (127,128).
Carbide burs and diamond grit burs are highly
effective for amalgam and gold alloy metals, and
diamond grit burs have been found to be highly
effective for cutting through non-precious metals
(129).
Access refinement
Ultrasonic tips are advantageous during endodontic
access preparation due to the ability to cut dentin very
precisely and conservatively, and due to visibility
unimpeded by the head of a high-speed handpiece
(Fig. 5). The selection of the tip for use depends upon
the task to be performed. For the gross removal of
dentin in an access preparation, an ultrasonic tip such
as the BUC-1, CPR-2D, or the BL-1 can be used as
these tips have a length suitable for most access
preparations, a strong tip that is less predisposed to
fracture, and abrasive grit along half of its length.
These ultrasonic tips allow us to identify, isolate, and
remove pulp stones from the pulp chamber; if the pulp
stone is large and occludes most of the pulp chamber,
the ultrasonic can be used to break and vibrate the
Fig. 5. A conservative access preparation through a
crown done with the aid of ultrasonic tips.
 Ultrasonics in endodontics

Fig. 6. (a) An access preparation into a lower molar shows the presence of a large pulp stone. (b) Removal of the large
pulp stone reveals several smaller pulp stones within the pulp chamber. Courtesy of Dr. B. Aljazaeri, Saudi Arabia.
(c) Several small pulp stones are seen during the process of removing the root of the pulp chamber. (d) Completed
access with removal of all of the pulp stones.

stone into smaller pieces for removal (Fig. 6). When a
pulp stones occludes the entrance to a canal orifice,
the ultrasonic tip can be used to carefully smooth the
pulp stone away. The BUC-2, BUC-2A, and BL-4
ultrasonic tips have a disk-like working end that is able
to smoothly plane attached pulp stones away when
used with a brush-like motion without gouging the
floor, and are thus good alternatives to ultrasonic tips
with a pointy end or a smaller working diameter.
The same tips can subsequently be used to unroof
pulp chambers and remove calcifications or interfering
dentin (Fig. 7). The tips can also be used to move
access line angles as required (Fig. 8). These tips can
then smooth the walls of the access preparations,
resulting in a smooth and clean pulp canal chamber
with straight-line access into each canal orifice.
Modification of the access preparation in this way
and troughing along the pulp floor to explore grooves
and isthmuses can greatly increase our ability to find
hidden and calcified canals (130); untreated root canal
anatomy is likely related to long-term failure of
endodontic treatment (131). In maxillary molars, the
high incidence of the second mesiobuccal canal makes
it important for clinicians to thoroughly search for
it (132); ultrasonic tips make this task easier and
predictable while conserving as much dentin as
possible (Fig. 9). The diameter of the working end of
most ultrasonic tips is smaller than most burs allotted
for this purpose and provides great control in
directionality. The ultrasonic tip is moved and lightly
brushed from the MB1 canal along the ithmus or in a
slightly mesial and palatal direction, and is generally

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Fig. 7. (a) This access was initiated by a clinician and referred to an endodontist when all of the canals could not be
located. (b) The pulp chamber was unroofed using ultrasonic tips. Courtesy of Dr. M. Ektefaie, Canada. (c) Ultrasonic
tips were used to refine the access and remove calcifications around the orifices. (d) Completed access to multiple
orifices in the mesial root of this mandibular molar. Courtesy of Dr. M. Braniste, Canada.

found at a distance of 1–3 mm from the MB1 orifice.
There is, of course, some variation in the location of
the second mesiobuccal canal, and its location can be
challenging, especially if the MB2 orifice separates
from the MB1 canal below the MB1 orifice, or is
located more than 3 mm from the MB1 orifice.
Also, any root with two or more canals will likely
contain an isthmus between the canals, such as in the
mesial roots of mandibular molars, or in the C-shaped
anatomy of mandibular molars. Ultrasonic tips are
used in such cases to explore and trough gently along
the isthmus, which aids in cleaning of the isthmus
and also in identifying additional canals that would
otherwise remain undiscovered and untreated, such as
middle mesial canals (Fig. 10). It is sometimes prudent
to use slightly longer ultrasonic tips, or those tips with
a slightly smaller diameter, for isthmus exploration and
removal due to the limited thickness of dentin, such as
the BUC-1A, CPR-3D, CPR-4D, or the BL-5.
Ultrasonic instrumentation
Technique
The powered cutting action of ultrasonically powered
K-files generated interest in the 1980s as a
more efficient and effective alternative to the
instrumentation of root canals by hand-powered
K-files. For the ultrasonic instrumentation technique,
a 10 K-file and a 15 K-file was used by hand to
working length. Then, the 15 K-file was placed into
the ultrasonic file adaptor, placed into the canal, and

138

Fig. 8. (a) A pulp stone was removed from this
maxillary molar. (b) The MB1 orifice is partially covered
by dentin. (c) An ultrasonic tip was used to remove the
interfering dentin and move the access line angle.
Courtesy of Dr. M. Ektefaie, Canada.
activated, moving in a push-and-pull motion for
approximately 1 min until the working length was
reached. Then, the 20 K-file was placed into the
ultrasonic adaptor, and this was repeated with
Ultrasonics in endodontics
Fig. 9. (a) Dentin is seen covering the region of the
MB2 orifice. (b) Ultrasonics were used to smooth away
the dentin to reveal the MB2 orifice. Courtesy of Dr. A.
Riyahi, Canada.
sequentially larger files until the desired apical size was
reached (133). Other instrumentation techniques in
addition to step-back procedures, such as step-down
or other modifications, have been reported as well
(134,135).
Canal cleanliness
An early study by Martin (136) showed that an
ultrasonically energized file was able to remove
more dentin than the same file used by hand
instrumentation, possibly due to what is described as a
dimensional planing effect. This effect of superior
debris removal from the root canal was confirmed by
other studies using resin canal models, as well as
extracted human teeth (137,138). Some studies
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Fig. 10. (a) Access preparation in the lower molar
reveals dentin covering the mesial canals. (b) Ultrasonic
tips are used to carefully smooth away dentin. (c) The
orifices, including a middle mesial canal, are found.
Courtesy of Dr. M. Braniste, Canada.
showed no difference in root canal cleanliness or debris
removal when comparing ultrasonic instrumentation
with several different techniques of hand
instrumentation; using extracted teeth as models,
140
SEM and histological evaluation showed little
difference in cleanliness (133,139,140). Apart from
the ambivalent results, it was also shown that no single
hand instrumentation or ultrasonic technique could
consistently completely clear a root canal of debris and
tissue (133).
Ultrasonic instrumentation as the sole modality of
root canal shaping and tapered preparation has not
been overwhelmingly adapted by clinicians; this
technique can result in the creation of irregular canal
shapes and straightening and transportation of the
canal—more than is seen with hand instrumentation
(141,142). Pre-curving the ultrasonic files was
reported to help prevent transportation and aid in
creating a continuous canal shape (143). However,
other difficulties were reported as well, such as the
frequent need to enlargen the canal by hand in order
to accommodate the next endosonic file, the lack of
tactile sensation, and the risk of file fracture if the tip
became bound during use (144). The time required
for ultrasonic instrumentation is also significantly
longer than hand instrumentation (144). Ultimately,
the preparation of root canals with rotary endodontic
files allows clinicians to efficiently produce a well-
centered and more tapered preparation in comparison
to ultrasonic or hand instrumentation, and
ultrasonically activated files are no longer used with
the intent to instrument or remove dentin from root
canal walls (145).
Although a few studies did conclude that
ultrasonically energized files were able to produce
significantly cleaner canals in comparison to hand
instrumentation, it was soon acknowledged that this
cleanliness was likely the result of not only mechanical
preparation, but also the ultrasonic activation of an
irrigant (146). In bactericidal studies, investigations
were done to determine whether the effect of
ultrasound itself through acoustic streaming and
cavitation was responsible for a bactericidal effect in
root canals, or whether the activation of a bactericidal
irrigant (by ultrasonic means) created a bactericidal
effect. One study found that cavitation could not be
generated by the ultrasonically energized 15 K-file at
the highest recommended power, meaning that the
strong cavitational forces that would be required to
disrupt bacteria were not created. It was determined in
another study that acoustic streaming alone was able
to kill bacteria in suspension in a time-dependent
manner, but after 15 min, the percentage of killed

bacteria had little clinical impact (147). Although
acoustic streaming may not have a direct effect on
bacteria, it may be able to loosen debris and bacterial
aggregations. A subsequent study confirmed the small
value of ultrasound by itself in killing bacteria in
suspension, instead demonstrating the efficacy of
sodium hypochlorite in killing the same bacteria in
suspension without any activation procedures (148).
Irrigation
It is generally accepted that ultrasonic instrumentation
is not an efficient or advantageous method of root
canal preparation and debridement by itself; this is also
reviewed in the previous section on instrumentation.
However, its role as a supplementary method of
irrigant agitation in helping to achieve improved
treatment outcomes by enhancing disinfection and
dissolution of tissue is becoming well established.
Agitation of the various irrigants used during root
canal treatment, whether by ultrasonic, sonic, or
manual techniques, has become a routine part of
endodontic treatment for many clinicians. It is also
seen by some as an additional step or option for teeth
with persistent infection, presenting as continuous
exudation or hemorrhage (149).
Canal cleanliness
An early study using resin root canal models measuring
residual radioisotope-laden gelatin found that an
additional ultrasonically activated procedure with a
smaller no. 15 finger plugger after hand or ultrasonic
instrumentation with a 30 K-file was completed
reduced the radioactivity significantly more than when
just hand or ultrasonic instrumentation was used
(150). The researchers in this study described trying to
make contact with the walls of the root canal model
with the ultrasonic tip using lateral pressure and
circular motions. A similar study in extracted human
teeth compared a hand-instrumented canal prepared
to a size 30 K-file using the step-back technique to the
same technique supplemented with an additional
3 min of ultrasonic agitation with a 15 K-file used
in a push-pull and circumferential motion, with
intermittent replenishment of irrigant (151). The
ultrasonic technique resulted in significantly cleaner
canals, as well as cleaner isthmuses.
Ultrasonics in endodontics
Acoustic microstreaming
The aforementioned studies were instructive, but
it was hard to deduce whether the additional
debridement was the result of a characteristic inherent
to ultrasonic activation of the irrigant, or the result of
the additional instrumentation in the form of pushing,
pulling, and/or circumferential motions and
irrigation. In 1987, this question was addressed by two
studies (63,66). The first study tried to detect
cavitation by ultrasonic files in an endodontic setting,
but none could be detected using several sizes of
files and various power levels (63). Instead, intense
acoustic microstreaming was detected and visualized.
In the next study, the possible effect of acoustic
microstreaming was investigated (66). After
instrumentation of two groups of teeth to a size 35
file, one group was subjected to an additional 5 min of
ultrasonic activation of the irrigant with a 15 K-file,
making sure that the file did not touch the canal walls
so that any effect seen could be attributed only to
acoustic microstreaming. The ultrasonic group had
cleaner root canal walls when viewed under SEM,
linking the results seen to the phenomenon of acoustic
streaming. Recent studies have also demonstrated the
effectiveness of ultrasonic activation after completion
of rotary instrumentation, resulting in improved smear
layer removal (152), debris removal from small
anatomical irregularities (153), and synergistic
behavior with irrigants to kill biofilm bacteria (114).
The ultrasonically energized irrigant may also be
effective in debris removal up to 3 mm beyond the
end of the file, unaffected by root canal curvature
(154). During acoustic streaming, which is optimally
performed with a 15 or 20 K-file placed at working
length or in the apical third, the irrigant streams about
the energized file in a series of smaller and larger
patterns (Fig. 11). Fewer streaming patterns are seen
with larger files (66). The best effect is said to be
achieved when the file is small, the displacement
amplitude is large, and the frequency of operation is
high (155). As much as possible, the ultrasonic file
needs to be able to oscillate freely as contact with the
root canal walls can modify the ability of the file to
vibrate and reduce the displacement amplitude
(71,156). Still, there are some studies that show
ultrasonic activation procedures after instrumentation
to be no more effective than conventional needle
irrigation in smear or debris removal (157,158) or in
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Fig. 11. (a) An ultrasonic handpiece is fitted with a file adaptor. (b) The file is placed into the prepared canals filled
with irrigant for passive ultrasonic irrigation. (c) The file is energized ultrasonically. Courtesy of Dr. M. Parhar,
Canada.
reducing the incidence of positive bacterial culture
results before obturation (159,160).
Passive ultrasonic irrigation
The technique of ultrasonic activation of an irrigant
after instrumentation has been completed has been
referred to as passive ultrasonic irrigation. The term
passive is used to denote the intention to simply
activate the irrigant, and not to cut or contact the
dentin with the activated file, thus differentiating it
from previous efforts to ultrasonically instrument the
root canal walls. During passive ultrasonic irrigation,
the irrigant is intermittently replenished using a
conventional irrigation syringe. Passive ultrasonic
irrigation has been shown to be equally effective with
a blank wire or a non-fluted finger spreader used in
place of a conventional fluted file, implying that the
use of a blank wire will prevent the creation of canal
irregularities, apical perforation, or transportation
(155,161). However, a recent study has shown that
the file-to-wall contact during passive ultrasonic
irrigation was actually rather significant; the file was in
contact with the wall 20% of the activation time, but
this contact time resulted in the file being affected 70%
of the contact time, resulting in low-frequency
142
secondary oscillations of the file and reduced
oscillation amplitude (69). As a result, the authors
have recommended amending the term “passive
ultrasonic irrigation” to “ultrasonically activated
irrigation.”
Continuous ultrasonic irrigation
Continuous ultrasonic irrigation is achieved by
simultaneously and continuously delivering irrigation
during ultrasonic activation through a water port
incorporated into the ultrasonic tip, such as the
ProUltra® PiezoFlow™ or the VPro™ StreamClean™
system. Unlike passive ultrasonic irrigation, the
replenishment of irrigant with a conventional syringe
between ultrasonic file activations is not required.
Continuous ultrasonic irrigation has been shown to be
more effective in clearing apically placed debris than
other irrigation modalities, such as conventional
syringe irrigation, manual dynamic activation, and
apical negative pressure (117,118). When comparing
passive ultrasonic irrigation and continuous ultrasonic
irrigation, both modalities have been shown to
perform similarly in the removal of debris in a root
canal (162). In another study, both modalities
performed comparably and better than conventional

syringe irrigation in the penetration of irrigant into
simulated lateral canals (116). Infected lateral canals
are a possible cause of recurrent or late endodontic
treatment failure; delivering irrigant to the entire root
canal system, including lateral canals, is important for
the predictable long-term success of endodontic
treatment (131).
Time of activation
The minimal or optimal amount of time needed to
ultrasonically activate an irrigant in order for a
beneficial effect to occur is unclear. One study
protocol, after complete instrumentation, used passive
ultrasonic irrigation for as little as 20 s to measure the
penetration of sodium hypochlorite into the dentinal
tubules; this amount of time resulted in significantly
greater penetration of irrigant in comparison to no
agitation or alternative agitation methods (163). For
the removal of the smear layer, one study reported
complete removal of the smear layer after passive
ultrasonic irrigation of sodium hypochlorite for 3 min
(164). Another study examining the amount of dead
bacteria in a biofilm after exposure to 2% chlorhexidine
solutions with or without ultrasonic agitation used
agitation time periods of 1 min and 3 min, revealing
that the percentage of killed bacteria depended upon
not only the time of exposure, but the chemical
formulation of the irrigant as well (114). Several study
protocols have shown significant improvement in
canal cleanliness after 1 min of ultrasonic activation
(116,165). More research in this area may help to
provide recommendations for minimum irrigant
activation times for a variety of irrigant formulations.
New innovations
The direction of future research on ultrasonics and
irrigation appears to be innovative, but also realizes
that effective enhancement of irrigation may require
multiple modalities of irrigant delivery and agitation.
One study has shown that the combination of apical
negative pressure and passive ultrasonic irrigation was
the only method able to deliver irrigant up to the
working length and into multiple lateral canals, in
comparison to apical negative pressure or passive
ultrasonic irrigation in isolation (166). Another recent
study used an emulsion containing micro-bubbles that
are energized ultrasonically to reduce Enterococcus
Ultrasonics in endodontics
faecalis biofilm beyond the level achieved with
ultrasonics and sodium hypochlorite together (167).
When the micro-bubbles are exposed to ultrasound,
there is increased bubble production, and it is thought
that the increased bubble dynamics as well as the
production of reactive oxygen species might be
responsible for the anti-biofilm activity.
Removal of intracanal medicaments
Finally, the use of a calcium hydroxide paste or similar
intracanal paste as an inter-appointment medicament is
used during multiple-visit treatments in order to
prevent the regrowth of root canal bacteria and has
been shown by many studies to improve the long-term
outcome of endodontic treatment (168,169). The
activation of calcium hydroxide itself for as little as
1 min has also been shown to increase the release of
calcium and favor a higher pH, which is beneficial in
resorption lesions (170). Its complete removal from the
root canal after it is used during treatment by irrigation
is known to be impossible, but generally desired.
Residual calcium hydroxide may interfere with sealer
penetration into the dentinal tubules (171). However,
the presence of residual calcium hydroxide may have no
impact on the bond strength of some popular sealers
such as AH26 Plus and iRoot SP (172). Residual
calcium hydroxide may predispose the root canal to
apical leakage when a zinc oxide eugenol-based sealer is
used (173), but the issue is debatable as one study
shows calcium hydroxide medicament does not
predispose a root canal to increased apical leakage
(174). Most studies reveal that the complete removal
of calcium hydroxide using instrumentation,
conventional irrigation, or activated irrigation methods
is not possible regardless of the technique (175). Some
studies show no advantage of passive ultrasonic
irrigation in removing calcium hydroxide (176), while
other studies show passive ultrasonic irrigation to
enhance its removal (177–179). Ultrasonic activation
time varied in these studies, ranging from 8–10 s per
canal up to 1 min per canal, so there is no consensus on
the amount of agitation time required for maximum
removal of an intracanal medicament. The choice of
irrigant may also affect calcium hydroxide removal
efficacy, with calcium chelating irrigants such as 17%
EDTA and 10% citric acid enabling greater removal of
calcium hydroxide (171,180). Again, this is not a
unanimous finding (175).
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Root filling procedures
Sealer distribution
Numerous methods have been used to distribute
root canal sealer into a root canal. In several studies
comparing placement of sealer by a hand instrument
or by ultrasonics, the use of ultrasonic energy for
the application of sealer resulted in a more thorough
and even covering of the root canals walls (181,182),
and more radiographically visible accessory canals
(183). However, even if this was the case, the
method of sealer placement may not have a
significant effect on apical leakage (184). One study
shows no difference in the placement and even
distribution of sealer when comparing hand files, a
lentulo spiral, ultrasonic files, or a master gutta-
percha cone (185). Other studies show that other
methods, such as using a lentulo spiral or an
irrigation needle, are better able to evenly distribute
a sealer layer in a root canal in comparison to
ultrasonic placement (186). Thus, at this time, there
is no overwhelming evidence for the ultrasonic
placement of sealer before obturation.
Obturation
One by-product of ultrasonic energy is heat energy.
When heat energy is transmitted by an ultrasonic tip or
file, the heat is able to soften gutta-percha material. A
very limited number of studies have investigated the
ability of using ultrasonic heat energy to soften and
subsequently compact gutta-percha either laterally or
vertically during obturation in order to achieve a more
dense root filling (187). Studies have shown that in
comparison to cold lateral condensation, using an
ultrasonic lateral condensation technique resulted in a
denser filling, fewer voids, and less apical microleakage
(188–191). Warm vertical compaction of gutta-
percha, whether using a traditional heat source or
ultrasonic vibrations, provided a similar sealing ability
(192). Softening gutta-percha using an ultrasonically
activated file or tip for the purpose of obturation is not
frequently used (188) but may be advantageous as the
file or tip is likely to cool quickly, preventing
inadvertent removal of the gutta-percha when
retracting the tip or plugger (188). More research is
indicated to establish whether the incorporation of
ultrasonic condensation of gutta-percha during
144
obturation can yield improved outcomes, particularly
with lateral condensation techniques.
Adaptation of MTA
Indirect ultrasonic activation has been suggested for
use to vibrate mineral trioxide aggregate (MTA) in
order to improve the adaptation of the material into
the root canal space, and to remove any voids in the
material. The indirect technique generally involves
placement of MTA using an appropriate carrier into
the root canal, and indirectly activating a condenser
placed in contact with the bulk of the MTA material
by pressing an ultrasonic tip in contact with the
condenser. A recent SEM study examining the
marginal adaptation of MTA found that indirect
ultrasonic activation in conjunction with smear layer
removal resulted in significantly improved marginal
adaptation (193). Indirect ultrasonic agitation during
placement also improved the compressive strength of
MTA (194), as well as the resistance to bacterial
leakage (195). However, a micro-CT analysis of MTA
root canal fillings found that a higher incidence of
voids within the material was present with indirect
ultrasonic activation; thus, this study recommends the
manual compaction of MTA with pluggers (196).
Many factors possibly affect the adaptation of MTA in
addition to the use of indirect ultrasonic activation,
such as the consistency of the mixed MTA, the time of
activation, and the power setting used. Further
research to determine the optimal conditions for
intimate material adaptation with the reduction of
voids is needed.
Re-treatment and
obstruction removal
Gutta-percha and paste removal
Gutta-percha can be removed by using ultrasonic tips.
An ultrasonic tip is selected that will passively fit into
the straight portion of a root canal and is activated
(Fig. 12). The heat produced will soften the gutta-
percha and the gutta-percha is displaced coronally as
the tip moves deeper into the canal. This method has
been found to be faster than using hand files to remove
gutta-percha (197). Unless used inappropriately, it
is unlikely that the heat associated with the
 Ultrasonics in endodontics

(a)

Fig. 12. An ultrasonic file (or appropriate ultrasonic tip)

is placed alongside the gutta-percha filling, which is
removed. Courtesy of Dr. M. Parhar, Canada.

thermosoftening of gutta-percha by ultrasonic

methods will exceed 10°C on the external root surface
(198). The use of rotary instruments are now
routinely used for the efficient removal of gutta-percha
from root canals, but supplementing rotary removal
with ultrasonic removal of gutta-percha and sealer
remnants from the walls under the dental operating
microscope can result in statistically significantly
(b)
cleaner walls (199). Hard-setting obturation materials
such as resorcinol–formalin paste have limited
solubility in solvents once set (200). Ultrasonic tips Fig. 13. (a) A lower molar with a paste-type obturation
material is re-treated. (b) The old obturation material
can be used to chip and sand away hard paste materials was removed using ultrasonic tips.
in the straight portions of a root canal; this requires
some patience (Fig. 13).

(205). However, the extent to which these various

Factors affecting post removal
The application of ultrasonics to almost every aspect of
re-treatment allows clinicians to save time, conserve
tooth structure, and avoid apical microsurgery. The
removal of an intraradicular post during re-treatment
can be difficult and time-consuming and, as such,
several studies have been done to discern predictable
methods of post removal. The efficacy and
effectiveness of post removal can be dependent upon
several factors, such as the depth of embedment of the
post into the root; the type, design, and material of
post fabrication; the type of tooth in which the post is
cemented; as well as the luting agent used to cement
the post (201–204). The particular ultrasonic device
used may also affect the efficiency of post removal
factors affect post retention after ultrasonic vibration is
not conclusive and requires further study. For instance,
a larger post diameter may require greater force to
remove after ultrasonic loosening than a thinner post
(206), while another study has shown that post
diameter is not related to efficacy of removal (207).
One study has shown that those posts cemented with
zinc phosphate and glass ionomer cements may have a
retentive force that is easier to disrupt in comparison
to resin cements, which may be largely unaffected by
ultrasonic vibrations (208,209). Other studies have
shown that the type of cement used does not influence
the amount of force required to remove the posts
after ultrasonic vibration, including resin cements
(210,211).

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Methods of post removal

Various methods of post removal are available, and

these methods are often combined to maximize
loosening of the post, or used sequentially if one
method is not making sufficient progress after several
minutes of use (212). Exposure of the post can be
accomplished by using a combination of surgical
length #2 and #4 round burs to remove the core
material. Ultrasonic tips such as the BUC-1 or
BUC-1A can be used to further remove cement and
core materials immediately around the post in a
circumferential manner without aggressively removing
dentin around the orifice and coronal third of the root,
as troughing or ditching with large burs around the
post can result in the excessive loss of tooth structure
(213). It is important to avoid the furcation area due
to the relative thinness of dentin, when applicable. At
this point, ultrasonic instrumentation for post removal
is the most commonly applied technique to loosen and
vibrate posts, a technique that has been used since the
late 1970s (201,213,214). Sonic instrumentation is
not effective for post removal (201). In order to
vibrate a post, the tip of the ultrasonic instrument,
typically a tip such as the ENDO-1 (Dentsply Tulsa),
CPR-1 (SybronEndo), VT (SybronEndo), or
VibraPost (VP) (B&L Biotech) is set at high power,
and the tip placed against the post. The ultrasonic
energy transfers to the post as vibrational mechanical
energy, and promotes the failure of the cement bond
(Fig. 14). When the tip is placed near the cervical
region of the tooth at an angle to the post, as opposed
to the most incisal position of the post, the force
required to dislodge the post is decreased; many
studies also place the ultrasonic tip on the post
approximately 2 mm from the tooth structure to
maximize the harmonics and conduction of energy
(201,215). The ultrasonic tip can also be moved up
and down along the post as well as circumferentially to
encourage further loosening. After sufficient loosening
Fig. 14. (a) A post is uncovered and the surrounding
of the post, the post can be picked out of the canal
core material is removed. (b) The surrounding core
with Stieglitz forceps or a similar tool. material has been removed. Ultrasonic tips are used to
For posts that have fractured at or near the level of remove visible cement from around the post and vibrate
the pulp floor, or are fully embedded within the root the post to promote disintegration of the cement seal.
canal, a small pointed ultrasonic tip such as the (c) The post has been removed.
BUC-1, ENDO-2, or ENDO-3 can first be used to
create space or a small gutter circumferentially or
alongside the post, where there is adequate thickness
of dentin to expose the coronal portion (216). This

146

may also involve carefully breaking up any visible core
and cement materials around the fractured post with
the ultrasonic tip. Loosening the fragment in such a
manner may dislodge the post. If possible, a post
vibration tip such as an ENDO-1, or a scaler tip, can
be placed against the exposed portion of the post; this
allows vibrations to be transmitted to the post and will
further shatter the integrity of the cement (216,217).
Removal of such a fractured post can be challenging
and requires some patience; judicious case selection
is also necessary, as sometimes other post removal
systems may be needed to remove a fractured post.
Time required for post removal
The amount of time required to sufficiently loosen a
post using ultrasonics varies, again, with the multiple
factors mentioned that affect post retention. Post
dislodgement has been found to occur in as little as
40 s, while other studies have found that often several
minutes of ultrasonic use are required, with one study
reporting 16 min to be the most effective amount of
time (203,212,218). One in vivo study recorded an
average of 7.7 min required for ultrasonic post
removal, with a range of approximately 2–13 min
(219). These study results are difficult to compare as
different ultrasonic devices, post types, and luting
materials are often used; one study found no beneficial
effect of ultrasonic vibration for 16 min (210) while
another study of 234 patient records reported all
posts requiring removal were successfully removed in
approximately 3 min (220). Additional factors such as
the extent of coronal disassembly, as well as the extent
of leakage before post removal is attempted, may affect
the ease with which posts are removed. In general
terms, if a post is not significantly loosened after
10–15 min of ultrasonic vibration, it may be wise to
consider further removal of cement around the post
with a thin and long ultrasonic tip, or using a different
post removal method.
Risks of post removal
There are some risks associated with post removal
using ultrasonic methods. One is the possibility of
causing cracks and/or fractures of the root dentin
during vibration and removal of a post. In an in vivo
study using cadaver teeth, cemented posts were
vibrated until removed, and the frequency of canal and
Ultrasonics in endodontics
intradentin cracks was analyzed in comparison to teeth
where the cemented posts were left in place or only
endodontic treatment without post placement was
provided (219). There was a statistically significant
higher incidence of cracks in those teeth where
ultrasonics was used for post removal, in comparison
to those teeth where only endodontic treatment was
provided. In those teeth where only post placement
was performed, there was also a fewer incidence of
cracks but the difference was not statistically significant
in comparison to the ultrasonic post removal group
(219). However, catastrophic root fracture is a rare
occurrence. A study of 1,600 teeth from which posts
were removed in a private clinic found a 0.06%
incidence of root fracture as a result of post removal
procedures, which also included ultrasonic use (220).
A survey of endodontic specialists has estimated a root
fracture incidence of 0.002%; this group reported
ultrasonic use to be the most common method of post
removal (214).
The other risk associated with post removal is the
production and conduction of heat from the ultrasonic
tip to the post, which can be transmitted to the
periodontal attachment apparatus. It is well known
that a temperature increase to 47°C for 1 min can
cause bone necrosis (108). It has been shown that
as little as 15–20 s of continuous dry ultrasonic
instrumentation can contribute to injurious heat
trauma, especially when high power settings are used
(73,221). The thickness or thinness of dentin around
a post has been shown to have no significant effect on
the increase in temperature (222). Heat transmission
of such magnitude through a post can result in loss of
bone, soft tissue, or teeth in the days and weeks after
the initial heat trauma. Dental rehabilitation after
heat trauma can be a lengthy and extensive process;
fortunately, this is not a frequent occurrence and the
use of ultrasonics for post removal is generally seen as
a safe and conservative procedure (223). Using very
short cycles of ultrasonic instrumentation coupled
with cooling procedures in between such as copious
water irrigation (15 mL/min and 30 mL/min have
been recommended by certain studies) can prevent
such trauma (109,224). A cotton pellet saturated with
Endo-Ice has also been shown to be as effective as
copious water cooling (73). Air cooling has also been
shown to be effective, but the conductivity of water—
and thus the ability to transfer heat away—is much
greater than air (225). It is also interesting to note that
147
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an in vitro study revealed that it can take between
20–30 s for a temperature gauge located at the cervical
area of an extracted tooth to drop 10°C to the baseline
temperature after cooling procedures are applied (73).
Removal of metallic files and obstructions
The removal of fractured instruments within a root
canal has become a safer and more predictable
procedure with the use of ultrasonics and the dental
operating microscope. Many techniques can be used
to attempt to remove fractured instruments, but the
management of fractured files should be also governed
by the evaluation of factors such as the location of the
file, the root curvature, and the presence of apical
disease (226). Aggressive file removal procedures can
induce additional stresses in a tooth that might initiate
vertical root fracture (227,228). The success rate for
removing or bypassing fractured instruments as
reported by studies has a variable range; one recent
study reports a success rate of 70.5%, including
fragments both visible and non-visible to the eye
under the microscope (229). The success of using
ultrasonics alone to remove fractured instruments has
been favorable, with studies reporting success rates of
54.4% (229) and as high as 93.3% (230). Another
recent paper reported a success rate of 80% when
using an ultrasonic technique to remove separated
instruments; this required an average of 36 min for file
removal (231).
Most recent studies use an ultrasonic file removal
method that closely follows or is a variation of the
Ruddle technique (231–233). This technique uses
modified Gates Glidden burs to create a “staging
platform” at the coronal aspect of the fractured
instrument. Then, fine ultrasonic tips of various
lengths are used without water to trough around the
most coronal part of the instrument in order to expose
it, followed by ultrasonic vibration of the instrument
fragment to loosen it. Counter-clockwise movements
of the tips can also be used to dislodge the fractured
file. Some appropriate ultrasonic tips are CPR #3–8
(Obtura Spartan) or ProUltra Endo #3–8 (Dentsply
Tulsa), with the longer and more flexible tips used for
deeper file locations (Fig. 15). A dental operating
microscope is required for this technique, and the
ability to visualize the file fragment is also required.
Attempts to use this technique with fragments located
beyond a curve in a root canal can result in significant
148
canal aberration, perforation, ledges, or weakening of
the root (234). The principle of this technique can also
be applied to the removal of silver points, although
braiding techniques using hand files to pull out silver
points may be used if or when space is available
alongside the obstruction (217). Alternative
techniques using the abrasive action of ultrasonics
have also been used to erode and eliminate silver
points and other obstructions; however, stainless-steel
obstructions and posts made of non-precious metals
will not benefit from this technique (235).
The removal of fractured instruments can also
induce high temperatures in the root canal walls
(110), and periodic cooling with air or water is also
recommended during the attempted removal of
separated files. It has been shown that fine tips such as
the CPR #5 and CPR #6 (Obtura Spartan) can be used
at low power settings for up to 60 s and 120 s,
respectively (111). However, care should be taken
with all tips used for 1–2 min to remove fine file
fragments as significant increases in temperature can
occur within this time period (110). A recent study has
evaluated the effectiveness of two ultrasonic tip designs
that enable the flow of air (in place of water) through
the tip to reduce the temperature rise during the
removal of fractured instruments (74). The ability to
provide a flow of air instead of water is a new feature of
the P-Max-XS ultrasonic device by Satelec/Acteon.
Both tip designs were shown to be effective in
reducing the increase in temperature measured on the
external root surface, but one particular tip designed
to direct air along the entire ultrasonic tip, as opposed
to the coronal two-thirds of the ultrasonic tip, was
shown to be significantly more effective (74).
Apical microsurgery
Traditional and modern apicoectomy
Surgical endodontic treatment has adopted new
materials, new techniques, and benefits from the use of
the surgical operating microscope. These changes have
resulted in predictable healing and higher incidences
of healing than when traditional techniques are used
(236–239). A recent meta-analysis indicates that root-
end surgery performed using a traditional technique
results in a 59% positive outcome, while root-end
surgery performed using modern microsurgery
techniques results in a 94% positive outcome (240).
 Ultrasonics in endodontics

Fig. 15. (a) A long hand file has been separated in a lower molar, with removal previously attempted using a
combination of burs and the braiding technique. (b) The case was then referred to an endodontist, where long and
thin ultrasonic tips were used to remove the instrument. Courtesy of Dr. M. Ektefaie, Canada. (c) A No. 3 Gates
Glidden has been separated in an upper molar and wedged into the palatal canal. (d) Ultrasonic instruments were used
to remove dentin around the head of the Gates Glidden and ultimately remove the separated drill.

The traditional technique generally involves root-end
resection with a 45 degree bevel angle and retrograde
preparation using a carbide bur. The modern
technique involves root-end resection with minimal or
no bevel, and a retrograde preparation using specially
designed ultrasonic retropreparation tips (Fig. 16). A
dental operating microscope is used for the modern
technique (237). Although a variety of root-end filling
materials can be used, the use of MTA is a material
well-supported by evidence. It is generally placed with
specialized carriers to the cavity preparation and
compacted with small pluggers. Ultrasonic vibration of
MTA may be able to improve the quality of sealing and
improve adaptation of the material to the walls of the
retropreparation (241).
Retropreparation
Root-end cavity preparation using an ultrasonic tip
results in higher-quality conservative preparations
with fewer occurrences of perforation than when
conventional micro-handpiece burs are used (242).
Using an ultrasonic retropreparation tip (or retrotip)
produces a more conservative preparation than a laser
tip (243). The resulting cavity preparation is centered
with parallel walls, follows the path of the original root

149
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(a)
(b)
Fig. 16. (a) Apical microsurgery of a maxillary incisor
during retropreparation with an ultrasonic retrotip.
(b) Continued removal of gutta-percha during the
retropreparation stage.
canal and/or isthmus, and can be standardized at a
depth of 3 mm, which is the minimum depth required
for an effective seal (244,245). Longer retrotips
are available and can be used when a deeper
retropreparation is required. The retrotip is used with
water irrigation. Fracture of the ultrasonic tip 2–3 mm
from the end is possible with use and coincides with the
bend, which can be acutely angled at 75° or 80° in
certain surgical tips. While the widely-used diamond-
coated retrotip has been found to be effective due to its
abrasive properties, the recently introduced stainless-
steel microprojection tip called JETip (B&L Biotech)
has been found to be equally effective. The diamond-
coated retrotips can lose a significant portion of the
150
diamond particles after repeated use (246); the JETips
do not appear to lose their microprojections (100).
Smear layer
Root-end preparations can result in the accumulation
of debris and in the production of a smear layer, which
may harbor bacteria and pulp remnants (247,248).
The removal of the smear layer has been advocated for
orthograde endodontics, and thus it seems reasonable
to remove potentially contaminated debris during
retrograde procedures as well (249). Demineralization
of resected root ends with 50% citric acid has also been
associated with more rapid and complete healing
in what is seen to be enhanced cementogenesis
(250). It has been found in one study that the smear
layer can be effectively removed by applying 35%
orthophosphoric acid gel for 15 s, followed by rinsing
with distilled water for 1 min (248). Using 35%
orthophosphoric acid resulted in improved smear layer
removal in comparison to a 24% EDTA gel (248).
Various chelating agents and organic acids of varying
concentrations have been tested for smear layer
removal, which is reflected in the various protocols
used in different studies (251). However, it has also
been shown that removal of the smear layer may not
improve bacterial leakage when a retropreparation is
filled with MTA; more research is indicated on
whether smear layer removal will improve clinical
healing after apical microsurgery (252).
Dentinal cracks
One concern with the use of ultrasonic retrotips for
cavity preparation is the possible creation of cracks at
the root-end, although the clinical impact is not
exactly clear (253). It is possible that cracks may
promote leakage, perhaps resulting in failure of apical
surgery procedures (254). It was shown in extracted
teeth that there were significantly more cracks in
the dentin when ultrasonics were used to create a
retropreparation in comparison to root resection
alone, with high power settings creating significantly
more cracks than when low power settings were
used (255). It was thought that this result may be
due to the use of extracted teeth unsupported by
a periodontal attachment; a subsequent study
comparing the incidence of cracks after ultrasonic
instrumentation at high and low power settings in

extracted teeth and cadaver teeth found no significant
difference between any group (256). A recent
cadaveric study also showed no difference in the
number of cracks after root-end cavity preparation
using three different power settings (257). Other
studies using extracted teeth have also reported no
significant difference in the number or type of cracks
after root-end resection alone or root-end preparation
(258,259). There was also no difference found in the
number of cracks created when comparing ultrasonic
retropreparation to the use of high-speed burs for
similar retropreparation (260), and ultrasonically
prepared cavities were able to achieve an effective seal
when filled with MTA, and even improved the sealing
ability of inferior retrofilling materials (261).
Diamond-coated retropreparation tips, which are
widely used, also do not appear to cause significant
root-end cracks (262), while stainless-steel tips are able
to cause a larger number of cracks than diamond-
coated tips (253). This, too, has been disputed, with a
different study reporting stainless-steel ultrasonic tips
to produce no root-end fractures (263).
Conclusions
The piezoelectric ultrasonic device has the potential
to become routinely incorporated into almost every
component of endodontic treatment, re-treatment,
and apical microsurgery. It is already indispensable as a
precise tool with which the most challenging clinical
situations, such as finding hidden root canals and
removing root canal obstructions, can be done with
relative ease, predictability, and conservancy. It can be
seen by the few innovative studies which take advantage
of the energizing ability of ultrasound that a thorough
understanding of how ultrasonic tips and files behave
with irrigants and tooth structure can produce methods
and conditions to truly enhance the beneficial effect of
such energy in the confined root canal space.
References
1. Mould RF. Marie and Pierre Curie and radium:
history, mystery, and discovery. Medical Physics 1999:
26: 1766–1772.
2. Arnau A, Soares D. Fundamentals of piezoelectricity.
In: Vives AA, ed. Piezoelectric Transducers and
Ultrasonics in endodontics
Applications. Berlin, Germany: Heidelberger, 2004:
1–37.
3. Ikeda T. Fundamentals of Piezoelectricity. New York,
NY: Oxford University Press, 1990.
4. Sodano HA, Inman DJ, Park G. A review of power
harvesting from vibration using piezoelectric materials.
Smart Mater Struct 2004: 16: R1–R21.
5. Lea SC, Walmsley AD. Mechano-physical and
biophysical properties of power-driven scalers: driving
the future of powered instrument design and
evaluation. Periodontol 2000 2009: 51: 63–78.
6. Yousefimanesh H, Robati M. A comparison of
magnetostrictive and piezoelectric ultrasonic scaling
devices: an in vitro study. J Periodontal Implant Sci
2012: 42: 243–247.
7. Balamuth L. “Method and means for removing
material from a solid body.” U.S. Patent 2,580,716,
January 1, 1952.
8. Cullity BD, Graham CD. Introduction to Magnetic
Materials, 2nd edn. Hoboken, New Jersey: Wiley &
Sons, 2009.
9. Clark SM. The ultrasonic dental unit: a guide for
the clinical application of ultrasonics in dentistry and in
dental hygiene. J Periodontol 1969: 40: 621–629.
10. Bains VK, Mohan R, Gundappa M, Bains R.
Properties, effects and clinical applications of
ultrasound in periodontics: an overview. Perio 2008:
5: 291–302.
11. Laird W, Walmsley AD. Ultrasound in dentistry. Part
1—biophysical interactions. J Dent 1991: 19: 14–17.
12. Postle HH. Ultrasonic cavity preparation. J Prosthet
Dent 1958: 8: 153–160.
13. Lefkowitz W, Robinson HBG, Postle HH. Pulp
response to cavity preparation. J Prosthet Dent 1958: 8:
315–324.
14. Street EV. A critical evaluation of ultrasonics in
dentistry. J Prosthet Dent 1959: 9: 132–141.
15. Schulein TM. The era of high speed development in
dentistry. J Hist Dent 2002: 50: 131–137.
16. Bittar DG, Murakami C, Hesse D, Imparato JCP,
Mendes FM. Efficacy of two methods for restorative
materials’ removal in primary teeth. J Contemp Dent
Pract 2011: 12: 372–378.
17. Carvalho CAR, Fagundes TC, Barata TJE,
Trava-Airoldi VJ, Navarro MFL. The use of CVD
diamond burs for ultraconservative cavity preparations:
a report of two cases. J Esthet Restor Dent 2007: 19:
19–28, discussion 29.
18. Antonio AG, Primo LG, Maia LC. Case report:
ultrasonic cavity preparation—an alternative approach
for caries removal in paediatric dentistry. Eur J
Paediatr Dent 2005: 6: 105–108.
19. Vieira ASB, Santos dos MPA, Antunes LAA, Primo
LG, Maia LC. Preparation time and sealing effect of
cavities prepared by an ultrasonic device and a high-
speed diamond rotary cutting system. J Oral Sci 2007:
49: 207–211.
20. Vanderlei AD, Borges ALS, Cavalcanti BN, Rode SM.
Ultrasonic versus high-speed cavity preparation:
151
Park
analysis of increases in pulpal temperature and time to
complete preparation. J Prosthet Dent 2008: 100:
107–109.
21. Lima LM, Motisuki C, Corat EJ, Santos-Pinto L.
Comparative cutting effectiveness of an ultrasonic
diamond tip and a high-speed diamond bur. Minerva
Stomatol 2009: 58: 93–98.
22. Mascarenhas Oliveira AC, Monti Lima L, Santos-Pinto
L. Influence of cutting instruments and adhesive
systems on hybrid layer formation. Minerva Stomatol
2012: 61: 57–63.
23. Ellis R, Bennani V, Purton D, Chandler N, Lowe B.
The effect of ultrasonic instruments on the quality of
preparation margins and bonding to dentin. J Esthet
Restor Dent 2011: 24: 278–285.
24. Laufer B-Z, Pilo R, Cardash HS. Surface roughness
of tooth shoulder preparations created by rotary
instrumentation, hand planing, and ultrasonic
oscillation. J Esthet Restor Dent 1996: 75: 4–8.
25. Pedro R de L, Antunes LAA, Vieira ÁSB, Maia LC.
Analysis of primary and permanent molars prepared
with high speed and ultrasonic abrasion systems. J Clin
Pediatr Dent 2007: 32: 49–52.
26. Horne P, Bennani V, Chandler N, Purton D.
Ultrasonic margin preparation for fixed prosthodontics:
a pilot study. J Esthet Restor Dent 2012: 24: 201–209.
27. Vieira ÁSB, de Lima Pedro R, dos Santos Antunes L,
Alves dos Santos MP, Antunes LAA, Primo LG, Maia
LC. Topography and presence of a smear layer in
deciduous molars prepared with high-speed cutting
and ultrasonic abrasion: an in vitro study. Acta Odontol
Scand 2011: 69: 165–169.
28. Zinner DD. Recent ultrasonic studies, including
periodontia, without the use of an abrasive. J Dent Res
1955: 34: 9.
29. Busslinger A, Lampe K, Beuchat M, Lehmann B. A
comparative in vitro study of a magnetostrictive and a
piezoelectric ultrasonic scaling instrument. J Clin
Periodontol 2001: 28: 642–649.
30. Damoulis P, Fine JB, Greenstein G. Position paper:
sonic and ultrasonic scalers in periodontics. Research,
Science and Therapy Committee of the American
Academy of Periodontology. J Periodontol 2000: 71:
1792–1801.
31. Richman MJ. The use of ultrasonics in root canal
therapy and root resection. J Dent Med 1957: 12:
12–18.
32. Ehrlich A. Ultrasonic instrument cleaning. Dent Assist
1966: 35: 22.
33. Nicholson RJ, Stark MM, Scott HE Jr. Calculus and
stain removal from acrylic resin dentures. J Prosthet
Dent 1968: 20: 326–329.
34. Gross L, Hoffmann R, Jefson R. Ultrasonic precision
casting. Ultrasonics 1969: 7: 245–248.
35. Neal B. The ultrasonic cleaner. Dent Assist 1969: 38:
20.
36. Wilkinson RF, Maybury JE. Scanning electron
microscopy of the root surface following
instrumentation. J Periodontol 1973: 44: 559–563.
152
37. Woodruff HC, Levin MP. The effects of two ultrasonic
instruments on root surfaces. J Periodontol 1975: 46:
119–126.
38. Grieder A, Vinton PW, Cinotti WR, Kangur TT.
An evaluation of ultrasonic therapy for
temporomandibular joint dysfunction. Oral Surg Oral
Med Oral Pathol 1971: 31: 25–31.
39. Preiskel HW. Ultrasonic measurements of movements
of the working condyle. J Prosthet Dent 1972: 27:
607–615.
40. Walmsley AD. Ultrasound and root canal treatment:
the need for scientific evaluation. Int Endod J 1987:
20: 105–111.
41. Martin H. Ultrasonic disinfection of the root canal.
Oral Surg Oral Med Oral Pathol 1976: 42: 92–
99.
42. Sierra G, Boucher RMG. Ultrasonic synergistic effects
in liquid-phase chemical sterilization. Appl Environ
Microbiol 1971: 22: 160–164.
43. Boucher RMG, Pisano MA, Tortora G, Sawicki E.
Synergistic effects in sonochemical sterilization. Appl
Environ Microbiol 1967: 15: 1257–1261.
44. Bertrand G, Festal F, Barailly R. Use of ultrasound in
apicoectomy. Quintessence Int 1976: 7: 9–12.
45. Martin H, Cunningham W. Endosonic endodontics:
the ultrasonic synergistic system. Int Dent J 1984: 34:
198–203.
46. Martin H, Cunningham WT. The effect of endosonic
and hand manipulation on the amount of root canal
material extruded. Oral Surg Oral Med Oral Pathol
1982: 53: 611–613.
47. Cunningham WT, Martin H. A scanning electron
microscope evaluation of root canal debridement with
the endosonic ultrasonic synergistic system. Oral Surg
Oral Med Oral Pathol 1982: 53: 527–531.
48. Cunningham WT, Martin H, Pelleu GB, Stoops DE. A
comparison of antimicrobial effectiveness of endosonic
and hand root canal therapy. Oral Surg Oral Med Oral
Pathol 1982: 54: 238–241.
49. Carr G. Advanced techniques and visual enhancement
for endodontic surgery. Endod Rep 1992: 7: 6–9.
50. Plotino G, Pameijer CH, Grande NM. Ultrasonics in
endodontics: a review of the literature. J Endod 2007:
33: 81–95.
51. Felver B, Landini G, Walmsley AD. Three-dimensional
analyses of ultrasonic scaler oscillations. J Clin
Periodontol 2009: 36: 44–50.
52. Yap S, Stock C. A comparison in vitro of two ultrasonic
root canal preparation techniques. Int Endod J 1992:
25: 297–303.
53. Pavlíková G, Foltán R, Horká M, Hanzelka T.
Piezosurgery in oral and maxillofacial surgery. Int J
Oral Maillofac Surg 2011: 40: 451–457.
54. Schlee M, Steigmann M, Bratu E, Garg AK.
Piezosurgery: basics and possibilities. Implant Dent
2006: 15: 334–339.
55. Labanca M, Azzola F, Vinci R, Rodella LF.
Piezoelectric surgery: twenty years of use. Br J Oral
Maxillofac Surg 2008: 46: 265–269.

56. Degerliyurt K, Akar V, Denizci S, Yucel E. Bone lid
technique with piezosurgery to preserve inferior
alveolar nerve. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2009: 108: e1–e5.
57. Stübinger S, Kuttenberger J, Filippi A, Sader R,
Zeilhofer H-F. Intraoral piezosurgery: preliminary
results of a new technique. J Oral Maxillofac Surg
2005: 63: 1283–1287.
58. Parmar D, Mann M, Walmsley AD. Cutting
characteristics of ultrasonic surgical instruments. Clin
Oral Implants Res 2011: 22: 1385–1390.
59. Kocyigit ID, Atil F, Alp YE, Tekin U, Tuz HH.
Piezosurgery versus conventional surgery in radicular
cyst enucleation. J Craniofac Surg 2012: 23:
1805–1808.
60. Gülnahar Y, Hüseyin Köşger H, Tutar Y. A
comparison of piezosurgery and conventional surgery
by heat shock protein 70 expression. Int J Oral
Maxillofac Surg 2013: 42: 508–510.
61. Ahmad M, Roy RA, Kamarudin AG, Safar M.
The vibratory pattern of ultrasonic files driven
piezoelectrically. Int Endod J 1993: 26: 120–124.
62. Gulabivala K, Ng Y-L, Gilbertson M, Eames I. The
fluid mechanics of root canal irrigation. Physiol Meas
2010: 31: R49–R84.
63. Ahmad M, Pitt Ford TR, Crum LA. Ultrasonic
debridement of root canals: an insight into the
mechanisms involved. J Endod 1987: 13: 93–101.
64. Ahmad M, Roy RA, Kamarudin AG. Observations
of acoustic streaming fields around an oscillating
ultrasonic file. Dent Traumatol 1992: 8: 189–
194.
65. Walmsley AD, Lea SC, Felver B, King DC, Price GJ.
Mapping cavitation activity around dental
ultrasonic tips. Clin Oral Investig 2013: 17:
1227–1234.
66. Ahmad M, Pitt Ford TR, Crum LA. Ultrasonic
debridement of root canals: acoustic streaming and its
possible role. J Endod 1987: 13: 490–499.
67. Walmsley AD, Laird WR, Lumley PJ. Ultrasound in
dentistry. Part 2—Periodontology and endodontics.
J Dent 1992: 20: 11–17.
68. Walmsley AD, Felver B, Lea SC, Lumley PJ, King DC,
Price GJ. Identifying cavitation around dental
ultrasonic instruments. In: 39th International Congress
on Noise Control Engineering 2010, INTER-NOISE
2010: 8: 6593–6600.
69. Boutsioukis C, Verhaagen B, Walmsley AD, Versluis
M, van der Sluis LWM. Measurement and visualization
of file-to-wall contact during ultrasonically activated
irrigation in simulated canals. Int Endod J 2013: 46:
1046–1055.
70. Walmsley AD, Laird WRE, Williams AR. Displacement
amplitude as a measure of the acoustic output of
ultrasonic scalers. Dent Mater 1986: 2: 97–100.
71. Ahmad M, Pitt Ford TR, Crum LA, Walton AJ.
Ultrasonic debridement of root canals: acoustic
cavitation and its relevance. J Endod 1988: 14:
486–493.
Ultrasonics in endodontics
72. Lea SC, Landini G, Walmsley AD. Thermal imaging of
ultrasonic scaler tips during tooth instrumentation.
J Clin Periodontol 2004: 31: 370–375.
73. Davis S, Gluskin AH, Livingood PM, Chambers DW.
Analysis of temperature rise and the use of coolants in
the dissipation of ultrasonic heat buildup during post
removal. J Endod 2010: 36: 1892–1896.
74. Madarati AA, Qualtrough A, Watts DC. Efficiency of a
newly designed ultrasonic unit and tips in reducing
temperature rise on root surface during the removal of
fractured files. J Endod 2009: 35: 896–899.
75. Macedo RG, Verhaagen B, Wessenlink PR, Versluis M,
van der Sluis LW. Influence of refreshment/activation
cycles and temperature rise on the reaction rate of
sodium hypochlorite with bovine dentine during
ultrasonic activated irrigation. Int Endod J 2013: doi:
10.1111/iej.12125 [Epub ahead of print].
76. Stojicic S, Zivkovic S, Qian W, Zhang H, Haapasalo
M. Tissue dissolution by sodium hypochlorite: effect of
concentration, temperature, agitation, and surfactant.
J Endod 2010: 36: 1558–1562.
77. Trenter SC, Walmsley AD. Ultrasonic dental scaler:
associated hazards. J Clin Periodontol 2003: 30:
95–101.
78. Yamada H, Ishihama K, Yasuda K, Hasumi-Nakayama
Y, Shimoji S, Furusawa K. Aerial dispersal of blood-
contaminated aerosols during dental procedures.
Quintessence Int 2011: 42: 399–405.
79. Harrel SK, Barnes JB. Reduction of aerosols produced
by ultrasonic sealers. J Periodontol 1996: 67: 28–32.
80. Timmerman MF, Menso L, Steinfort J, van Winkelhoff
AJ, van der Weijden GA. Atmospheric contamination
during ultrasonic scaling. J Clin Periodontol 2004: 31:
458–462.
81. Feres M, Figueiredo LC, Faveri M, Stewart B, de Vizio
W. The effectiveness of a preprocedural mouthrinse
containing cetylpyridinium chloride in reducing
bacteria in the dental office. J Am Dent Assoc 2010:
141: 415–422.
82. Reddy S, Prasad MGS, Kaul S, Satish K, Kakarala S,
Bhowmik N. Efficacy of 0.2% tempered chlorhexidine
as a pre-procedural mouth rinse: a clinical study.
J Indian Soc Periodontol 2012: 16: 213–217.
83. Rezai FR. Dental treatment of patient with a cardiac
pacemaker: review of the literature. Oral Surg Oral
Med Oral Pathol 1977: 44: 662–665.
84. Miller CS, Leonelli FM, Latham E. Selective
interference with pacemaker activity by electrical
dental devices. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1998: 85: 33–36.
85. Stoopler ET, Sia YW, Kuperstein AS. Does ultrasonic
dental equipment affect cardiovascular implantable
electronic devices? J Can Dent Assoc 2011: 77:
b113.
86. Glassman G. The expanded role of ultrasonics in
endodontic treatment. Oral Health 2010: 38–52.
87. Lea SC, Landini G. Reconstruction of dental
ultrasonic scaler 3D vibration patterns from phase-
related data. Med Eng Phys 2010: 32: 673–677.
153
Park
88. Lea SC, Landini G, Walmsley AD. Vibration
characteristics of ultrasonic scalers assessed with
scanning laser vibrometry. J Dent 2002: 30: 147–151.
89. Jepsen S, Ayna M, Hedderich J, Eberhard J.
Significant influence of scaler tip design on root
substance loss resulting from ultrasonic scaling: a
laserprofilometric in vitro study. J Clin Periodontol
2004: 31: 1003–1006.
90. Paz E, Satovsky J, Moldauer I. Comparison of the
cutting efficiency of two ultrasonic units utilizing two
different tips at two different power settings. J Endod
2005: 31: 824–826.
91. Lumley PJ, Walmsley AD. Inherent variability in the
power output of endosonic instruments. Int Endod J
1991: 24: 298–302.
92. Lea SC, Landini G, Walmsley AD. Displacement
amplitude of ultrasonic scaler inserts. J Clin
Periodontol 2003: 30: 505–510.
93. Tomson P, Lea SC, Lumley PJ, Walmsley AD.
Performance of ultrasonic retrograde systems. J Endod
2007: 33: 574–577.
94. Dentkos TR, Berzins DW. Evaluation of cutting
efficiency of orthograde ultrasonic tips by using a
nonstatic model. J Endod 2008: 34: 863–865.
95. Lawlor K, Yelton C, Kulild J, Walker MP. Dentin
removal efficacy over time of the Buc-1 ultrasonic tip.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2010: 109: e107–e109.
96. Cottle E, Kulild JC, Walker MP. A comparison of
dentin cutting efficiency of 4 round-tipped ultrasonic
instruments. J Endod 2013: 39: 1051–1053.
97. Lin Y-H, Mickel AK, Jones JJ, Montagnese TA,
González AF. Evaluation of cutting efficiency of
ultrasonic tips used in orthograde endodontic
treatment. J Endod 2006: 32: 359–361.
98. Peters CI, Peters OA, Barbakow F. An in vitro study
comparing root-end cavities prepared by diamond-
coated and stainless-steel ultrasonic retrotips. Int
Endod J 2001: 34: 142–148.
99. Ishikawa H, Sawada N, Kobayashi C, Suda H.
Evaluation of root-end cavity preparation using
ultrasonic retrotips. Int Endod J 2003: 36: 586–
590.
100. Liu Z, Zhang D, Li Q, Xu Q. Evaluation of root-end
preparation with a new ultrasonic tip. J Endod 2013:
39: 820–823.
101. Cloutier DL, Kulild JC, Walker MP. A novel
methodology to evaluate the use of an ultrasonic tip.
J Endod 2011: 37: 1264–1267.
102. Yelton C, Lawlor K, Kulild JC, Walker MP.
Comparison of the efficiency of four different
ultrasonic tips to remove dentin over time. J Endod
2010: 36: 529–531.
103. Godfrey MP, Kulild JC, Walker MP. A comparison of
the dentin cutting efficiency of 4 pointed ultrasonic
tips. J Endod 2013: 39: 897–900.
104. Claire S, Lea SC, Walmsley AD. Characterisation of
bone following ultrasonic cutting. Clin Oral Investig
2013: 17: 905–912.
154
105. Iqbal MK. Nonsurgical ultrasonic endodontic
instruments. Dent Clin North Am 2004: 48: 19–34.
106. Walmsley AD, Lumley PJ, Johnson WT. Breakage of
ultrasonic root-end preparation tips. J Endod 1996:
22: 287–289.
107. Zeltner M, Peters OA, Paqué F. Temperature changes
during ultrasonic irrigation with different inserts and
modes of activation. J Endod 2009: 35: 573–577.
108. Eriksson AR, Albrektsson T. Temperature threshold
levels for heat-induced bone tissue injury: a vital-
microscopic study in the rabbit. J Prosthet Dent 1983:
50: 101–107.
109. Budd JC, Gekelman D, White JM. Temperature rise of
the post and on the root surface during ultrasonic post
removal. Int Endod J 2005: 38: 705–711.
110. Hashem A. Ultrasonic vibration: temperature rise on
external root surface during broken instrument
removal. J Endod 2007: 33: 1070–1073.
111. Madarati AA, Qualtrough AJ, Watts DC. Factors
affecting temperature rise on the external root surface
during ultrasonic retrieval of intracanal separated files.
J Endod 2008: 34: 1089–1092.
112. Paqué F, Balmer M, Attin T, Peters OA. Preparation of
oval-shaped root canals in mandibular molars using
nickel–titanium rotary instruments: a micro-computed
tomography study. J Endod 2010: 36: 703–707.
113. Solomonov M, Paqué F, Fan B, Eilat Y, Berman LH.
The challenge of C-shaped canal systems: a
comparative study of the self-adjusting file and
ProTaper. J Endod 2012: 38: 209–214.
114. Shen Y, Stojicic S, Qian W, Olsen I, Haapasalo M. The
synergistic antimicrobial effect by mechanical agitation
and two chlorhexidine preparations on biofilm
bacteria. J Endod 2010: 36: 100–104.
115. Adcock JM, Sidow SJ, Looney SW, Liu Y, McNally K,
Lindsey K, Tay FR. Histologic evaluation of canal and
isthmus debridement efficacies of two different irrigant
delivery techniques in a closed system. J Endod 2011:
37: 544–548.
116. Castelo-Baz P, Martín-Biedma B, Cantatore G,
Ruíz-Piñón M, Bahillo J, Rivas-Mundiña B,
Varela-Patiño P. In vitro comparison of passive and
continuous ultrasonic irrigation in simulated lateral
canals of extracted teeth. J Endod 2012: 38: 688–691.
117. Curtis TO, Sedgley CM. Comparison of a continuous
ultrasonic irrigation device and conventional needle
irrigation in the removal of root canal debris. J Endod
2012: 38: 1261–1264.
118. Jiang L-M, Lak B, Eijsvogels LM, Wesselink P, van der
Sluis LWM. Comparison of the cleaning efficacy of
different final irrigation techniques. J Endod 2012: 38:
838–841.
119. Gutarts R, Nusstein J, Reader A, Beck M. In vivo
debridement efficacy of ultrasonic irrigation following
hand-rotary instrumentation in human mandibular
molars. J Endod 2005: 31: 166–170.
120. Lea SC, Walmsley AD, Lumley PJ. Analyzing
endosonic root canal file oscillations: an in vitro
evaluation. J Endod 2010: 36: 880–883.

121. Howard RK, Kirkpatrick TC, Rutledge RE, Yaccino
JM. Comparison of debris removal with three
different irrigation techniques. J Endod 2011: 37:
1301–1305.
122. Park E, Shen Y, Khakpour M, Haapasalo M. Apical
pressure and extent of irrigant flow beyond the needle
tip during positive-pressure irrigation in an in vitro
root canal model. J Endod 2013: 39: 511–515.
123. Malentacca A, Uccioli U, Zangari D, Lajolo C, Fabiani
C. Efficacy and safety of various active irrigation devices
when used with either positive or negative pressure: an
in vitro study. J Endod 2012: 38: 1622–1626.
124. Mostafa DH, Agroudi El MA. Margin assessment and
fracture resistance of adhesively luted ceramic crowns.
J Am Sci 2010: 6: 264–273.
125. Rizkalla AS, Jones DW. Indentation fracture
toughness and dynamic elastic moduli for commercial
feldspathic dental porcelain materials. Dent Mater
2004: 20: 198–206.
126. Sutherland JK, Teplitsky PE, Moulding MB.
Endodontic access of all-ceramic crowns. J Prosthet
Dent 1989: 61: 146–149.
127. Haselton DR, Lloyd PM, Johnson WT. A comparison
of the effects of two burs on endodontic access in
all-ceramic high lucite crowns. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2000: 89: 486–492.
128. Sabourin CR, Flinn BD, Pitts DL, Gatten TL, Johnson
JD. A novel method for creating endodontic access
preparations through all-ceramic restorations: air
abrasion and its effect relative to diamond and carbide
bur use. J Endod 2005: 31: 616–619.
129. Stokes AN, Tidmarsh BG. A comparison of diamond
and tungsten carbide burs for preparing endodontic
access cavities through crowns. J Endod 1988: 14:
550–553.
130. Weller RN, Hartwell GR. The impact of improved
access and searching techniques on detection of the
mesiolingual canal in maxillary molars. J Endod 1989:
15: 82–83.
131. Vieira AR, Siqueira JF Jr, Ricucci D, Lopes WSP.
Dentinal tubule infection as the cause of recurrent
disease and late endodontic treatment failure: a case
report. J Endod 2012: 38: 250–254.
132. Somma F, Leoni D, Plotino G, Grande NM,
Plasschaert A. Root canal morphology of the
mesiobuccal root of maxillary first molars: a micro-
computed tomographic analysis. Int Endod J 2009:
42: 165–174.
133. Siqueira JF Jr, Araújo MC, Garcia PF, Fraga RC,
Dantas CJ. Histological evaluation of the effectiveness
of five instrumentation techniques for cleaning the
apical third of root canals. J Endod 1997: 23:
499–502.
134. Lumley PJ, Walmsley AD, Walton RE, Rippin JW.
Cleaning of oval canals using ultrasonic or sonic
instrumentation. J Endod 1993: 19: 453–457.
135. Murgel C, Walmsley AD, Walton RE. The efficacy
of step-down procedures during endosonic
instrumentation. J Endod 1991: 17: 111–115.
Ultrasonics in endodontics
136. Martin H, Cunningham WT, Norris JP. Ultrasonic
versus hand filing of dentin: a quantitative study. Oral
Surg Oral Med Oral Pathol 1980: 49: 79–81.
137. Yamaguchi M, Matsumori M, Ishikawa H, Sakurai T,
Nakamura H, Naitoh M, Shiojima M, Kikuchi A. The
use of ultrasonic instrumentation in the cleansing and
enlargement of the root canal. Oral Surg Oral Med
Oral Pathol 1988: 65: 349–353.
138. Tang M, Stock C. The effects of hand, sonic and
ultrasonic instrumentation on the shape of curved root
canals. Int Endod J 1989: 22: 55–63.
139. Cymerman JJ, Jerome LA, Moodnik RM. A scanning
electron microscope study comparing the efficacy of
hand instrumentation with ultrasonic instrumentation
of the root canal. J Endod 1983: 9: 327–331.
140. Baker MC, Ashrafi SH, Van Cura JE, Remeikis NA.
Ultrasonic compared with hand instrumentation: a
scanning electron microscope study. J Endod 1988:
14: 435–440.
141. Kielt LW, Montgomery S. The effect of endosonic
instrumentation in simulated curved root canals.
J Endod 1987: 13: 215–219.
142. Loushine RJ, Norman Weller R, Hartwell GR.
Stereomicroscopic evaluation of canal shape following
hand, sonic, and ultrasonic instrumentation. J Endod
1989: 15: 417–421.
143. Lumley PJ, Walmsley AD. Effect of precurving on the
performance of endosonic K files. J Endod 1992: 18:
232–236.
144. Pedicord D, ElDeeb ME, Messer HH. Hand versus
ultrasonic instrumentation: its effect on canal shape and
instrumentation time. J Endod 1986: 12: 375–381.
145. Zmener O, Banegas G. Comparison of three
instrumentation techniques in the preparation of
simulated curved root canals. Int Endod J 1996: 29:
315–319.
146. Cunningham WT, Martin H, Forrest WR. Evaluation
of root canal débridement by the endosonic ultrasonic
synergistic system. Oral Sur Oral Med Oral Pathol
1982: 53: 401–404.
147. Ahmad M. Effect of ultrasonic instrumentation on
Bacteroides intermedius. Dent Traumatol 1989: 5:
83–86.
148. Ahmad M, Pitt Ford TR, Crum LA, Wilson RF.
Effectiveness of ultrasonic files in the disruption of root
canal bacteria. Oral Surg Oral Med Oral Pathol 1990:
70: 328–332.
149. Tsurumachi T, Takita T, Hashimoto K, Katoh T,
Ogiso B. Ultrasonic irrigation of a maxillary lateral
incisor with perforation of the apical third of the root.
J Oral Sci 2010: 52: 659–663.
150. Weller RN, Brady JM, Bernier WE. Efficacy of
ultrasonic cleaning. J Endod 1980: 6: 740–743.
151. Archer R, Reader A, Nist R, Beck M, Meyers WJ. An
in vivo evaluation of the efficacy of ultrasound after
step-back preparation in mandibular molars. J Endod
1992: 18: 549–552.
152. Andrabi SM, Kumar A, Zia A, Iftekhar H, Alam S,
Siddiqui S. Effect of passive ultrasonic irrigation and
155
Park
manual dynamic irrigation on smear layer removal
from root canals in a closed apex in vitro model.
J Investig Clin Dent 2013: doi: 10.1111/jicd.12033
[Epub ahead of print].
153. Rödig T, Sedghi M, Konietschke F, Lange K, Ziebolz
D, Hülsmann M. Efficacy of syringe irrigation,
RinsEndo and passive ultrasonic irrigation in
removing debris from irregularities in root canals
with different apical sizes. Int Endod J 2010: 43:
581–589.
154. Malki M, Verhaagen B, Jiang L-M, Nehme W,
Naaman A, Versluis M, Wesselink P, van der Sluis L.
Irrigant flow beyond the insertion depth of an
ultrasonically oscillating file in straight and curved root
canals: visualization and cleaning efficacy. J Endod
2012: 38: 657–661.
155. Van der Sluis LWM, Wu MK, Wesselink PR. A
comparison between a smooth wire and a K-file in
removing artificially placed dentine debris from root
canals in resin blocks during ultrasonic irrigation. Int
Endod J 2005: 38: 593–596.
156. Lea SC, Walmsley AD, Lumley PJ. Analyzing
endosonic root canal file oscillations: an in vitro
evaluation. J Endod 2010: 36: 880–883.
157. Goode N, Khan S, Eid AA, Niu L-N, Gosier J, Susin
LF, Pashley DH, Tay FR. Wall shear stress effects of
different endodontic irrigation techniques and
systems. J Dent 2013: 41: 636–641.
158. Castagna F, Rizzon P, da Rosa RA, Santini MF,
Barreto MS, Duarte MA, Só MV. Effect of passive
ultrassonic instrumentation as a final irrigation
protocol on debris and smear layer removal—a SEM
analysis. Microsc Res Tech 2013: 76: 496–502.
159. Paiva SSM, Siqueira JF Jr, Rôças IN, Carmo FL,
Ferreira DC, Curvelo JAR, Soares RM, Rosado AS.
Supplementing the antimicrobial effects of
chemomechanical debridement with either passive
ultrasonic irrigation or a final rinse with chlorhexidine:
a clinical study. J Endod 2012: 38: 1202–1206.
160. Paiva SSM, Siqueira JF Jr, Rôças IN, Carmo FL, Leite
DCA, Ferreira DC, Rachid CT, Rosado AS. Molecular
microbiological evaluation of passive ultrasonic
activation as a supplementary disinfecting step: a
clinical study. J Endod 2013: 39: 190–194.
161. Munley PJ, Goodell GG. Comparison of passive
ultrasonic debridement between fluted and nonfluted
instruments in root canals. J Endod 2007: 33:
578–580.
162. van der Sluis L, Wu MK, Wesselink P. Comparison of
2 flushing methods used during passive ultrasonic
irrigation of the root canal. Quintessence Int 2009: 40:
875–879.
163. Paragliola R, Franco V, Fabiani C, Mazzoni A, Nato F,
Tay FR, Breschi L, Grandini S. Final rinse
optimization: influence of different agitation
protocols. J Endod 2010: 36: 282–285.
164. Cameron JA. The use of ultrasonics in the removal of
the smear layer: a scanning electron microscope study.
J Endod 1983: 9: 289–292.
156
165. Burleson A, Nusstein J, Reader A, Beck M. The
in vivo evaluation of hand/rotary/ultrasound
instrumentation in necrotic, human mandibular
molars. J Endod 2007: 33: 782–787.
166. Spoorthy E, Velmurugan N, Ballal S, Nandini S.
Comparison of irrigant penetration up to working
length and into simulated lateral canals using various
irrigating techniques. Int Endod J 2013: 46: 815–822.
167. Halford A, Ohl C-D, Azarpazhooh A, Basrani B,
Friedman S, Kishen A. Synergistic effect of
microbubble emulsion and sonic or ultrasonic
agitation on endodontic biofilm in vitro. J Endod
2012: 38: 1530–1534.
168. Shuping GB, Ørstavik D, Sigurdsson A, Trope M.
Reduction of intracanal bacteria using nickel–titanium
rotary instrumentation and various medications. J
Endod 2000: 26: 751–755.
169. Vera J, Siqueira JF Jr, Ricucci D, Loghin S, Fernández
N, Flores B, Cruz AG. One- versus two-visit
endodontic treatment of teeth with apical
periodontitis: a histobacteriologic study. J Endod
2012: 38: 1040–1052.
170. Duarte MAH, Balan NV, Zeferino MA, Vivan RR,
Morais CAH, Tanomaru-Filho M, Ordinola-Zapata R,
Moraes IG. Effect of ultrasonic activation on pH and
calcium released by calcium hydroxide pastes in
simulated external root resorption. J Endod 2012: 38:
834–837.
171. Çalt S, Serper A. Dentinal tubule penetration of root
canal sealers after root canal dressing with calcium
hydroxide. J Endod 1999: 25: 431–433.
172. Amin SAW, Seyam RS, El-Samman MA. The effect of
prior calcium hydroxide intracanal placement on the
bond strength of two calcium silicate-based and an
epoxy resin-based endodontic sealer. J Endod 2012:
38: 696–699.
173. Kim SK, Kim YO. Influence of calcium hydroxide
intracanal medication on apical seal. Int Endod J 2002:
35: 623–628.
174. Porkaew P, Retief DH, Barfield RD, Lacefield WR,
Soong SJ. Effects of calcium hydroxide paste as an
intracanal medicament on apical seal. J Endod 1990:
16: 369–374.
175. Kenee DM, Allemang JD, Johnson JD, Hellstein J,
Nichol BK. A quantitative assessment of efficacy of
various calcium hydroxide removal techniques.
J Endod 2006: 32: 563–565.
176. Balvedi R, Versiani MA, Manna FF. A comparison of
two techniques for the removal of calcium hydroxide
from root canals. Int Endod J 2010: 43: 763–768.
177. Yücel AÇ, Gürel M, Güler E, Karabucak B.
Comparison of final irrigation techniques in removal
of calcium hydroxide. Aust Endod J 2011: doi:
10.1111/j.1747–4477.2011.00326.x.
178. Wiseman A, Cox TC, Paranjpe A, Flake NM, Cohenca
N, Johnson JD. Efficacy of sonic and ultrasonic
activation for removal of calcium hydroxide
from mesial canals of mandibular molars: a
microtomographic study. J Endod 2011: 37: 235–238.

179. Taşdemir T, Celik D, Er K, Yildirim T. Efficacy of
several techniques for the removal of calcium
hydroxide medicament from root canals. Int Endod J
2011: 44: 505–509.
180. Nandini S, Velmurugan N, Kandaswamy D. Removal
efficiency of calcium hydroxide intracanal medicament
with two calcium chelators: volumetric analysis using
spiral CT, an in vitro study. J Endod 2006: 32:
1097–1101.
181. Hoen MM, LaBounty GL, Keller DL. Ultrasonic
endodontic sealer placement. J Endod 1988: 14:
169–174.
182. West LA, LaBounty GL, Keller DL. Obturation quality
utilizing ultrasonic cleaning and sealer placement
followed by lateral condensation with gutta-percha.
J Endod 1989: 15: 507–511.
183. Stamos DE, Gutmann JL, Gettleman BH. In vivo
evaluation of root canal sealer distribution. J Endod
1995: 21: 177–179.
184. Aguirre AM, el-Deeb ME, Aguirre R. The effect of
ultrasonics on sealer distribution and sealing of root
canals. J Endod 1997: 23: 759–764.
185. Wiemann AH, Wilcox LR. In vitro evaluation of four
methods of sealer placement. J Endod 1991: 17:
444–447.
186. Kahn FH, Rosenberg PA, Schertzer L, Korthals G,
Nguyen PN. An in vitro evaluation of sealer placement
methods. Int Endod J 1997: 30: 181–186.
187. Moreno A. Thermomechanically softened gutta-
percha root canal filling. J Endod 1977: 3: 186–188.
188. Bailey GC, Ng Y-L, Cunnington SA, Barber P,
Gulabivala K, Setchell DJ. Root canal obturation by
ultrasonic condensation of gutta-percha. Part II: an
in vitro investigation of the quality of obturation. Int
Endod J 2004: 37: 694–698.
189. Baumgardner KR, Krell KV. Ultrasonic condensation
of gutta-percha: an in vitro dye penetration and
scanning electron microscopic study. J Endod 1990:
16: 253–259.
190. Deitch AK, Liewehr FR, West LA, Patton WR. A
comparison of fill density obtained by supplementing
cold lateral condensation with ultrasonic
condensation. J Endod 2002: 28: 665–667.
191. Mente J, Werner S, Koch MJ, Henschel V, Legner M,
Staehle HJ, Friedman S. In vitro leakage associated
with three root-filling techniques in large and
extremely large root canals. J Endod 2007: 33:
306–309.
192. Re Cecconi D, Grassi M, Tortini D, Brambilla E,
Gagliani MM. Efficacy of ultrasonic vibration in warm
gutta-percha vertical compaction. Minerva Stomatol
2012: 61: 75–82.
193. Araújo AC, Nunes E, Fonseca AA, Cortes MI, Horta
MC, Silveira FF. Influence of smear layer removal and
application mode of MTA on the marginal adaptation
in immature teeth: a SEM analysis. Dent Traumatol
2013: 29: 212–217.
194. Basturk FB, Nekoofar MH, Günday M, Dummer PM.
The effect of various mixing and placement techniques
Ultrasonics in endodontics
on the compressive strength of mineral trioxide
aggregate. J Endod 2013: 39: 111–114.
195. Lawley GR, Schindler WG, Walker WA, Kolodrubetz
D. Evaluation of ultrasonically placed MTA and
fracture resistance with intracanal composite resin
in a model of apexification. J Endod 2004: 30:
167–172.
196. El-Ma’aita AM, Qualtrough AJE, Watts DC. A micro-
computed tomography evaluation of mineral trioxide
aggregate root canal fillings. J Endod 2012: 38:
670–672.
197. Ladley RW, Campbell AD, Hicks ML, Li S-H.
Effectiveness of halothane used with ultrasonic or hand
instrumentation to remove gutta-percha from the root
canal. J Endod 1991: 17: 221–224.
198. Sweatman T, Baumgartner J, Sakaguchi R. Radicular
temperatures associated with thermoplasticized gutta-
percha. J Endod 2001: 27: 512–515.
199. de Mello Junior JE, Cunha RS, Bueno CEDS, Zuolo
ML. Retreatment efficacy of gutta-percha removal
using a clinical microscope and ultrasonic instruments:
part I—an ex vivo study. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2009: 108: e59–e62.
200. Gambrel M, Hartwell G, Moon P, Cardon J. The
effect of endodontic solutions on resorcinol-formalin
paste in teeth. J Endod 2005: 31: 25–29.
201. Buoncristiani J, Seto BG, Caputo AA. Evaluation of
ultrasonic and sonic instruments for intraradicular post
removal. J Endod 1994: 20: 486–489.
202. Berbert A, Filho MT, Ueno AH, Bramante CM,
Ishikiriama A. The influence of ultrasound in removing
intraradicular posts. Int Endod J 1995: 28: 100–102.
203. Brito-Júnior M, Soares JA, Santos S. Comparison of
the time required for removal of intraradicular cast
posts using two Brazilian ultrasound devices. Braz
Oral Res 2009: 23: 17–22.
204. Soares JA, Brito-Júnior M, Fonseca DR. Influence of
luting agents on time required for cast post removal by
ultrasound: an in vitro study. J App Oral Sci 2009: 17:
145–149.
205. Dixon EB, Kaczkowski PJ, Nicholls JI, Harrington
GW. Comparison of two ultrasonic instruments for
post removal. J Endod 2002: 28: 111–115.
206. Alfredo E, Garrido ADB, Souza-Filho CB,
Correr-Sobrinho L, Sousa Neto MD. In vitro
evaluation of the effect of core diameter for removing
radicular post with ultrasound. J Oral Rehabil 2004:
31: 590–594.
207. Silva MRD, Biffi JCG, Mota ASD, Fernandes Neto AJ,
Neves FDD. Evaluation of intracanal post removal
using ultrasound. Braz Dent J 2004: 15: 119–126.
208. Garrido ADB, Fonseca TS, Alfredo E, Silva-Sousa
YTC, Sousa-Neto MD. Influence of ultrasound, with
and without water spray cooling, on removal of posts
cemented with resin or zinc phosphate cements. J
Endod 2004: 30: 173–176.
209. Gomes A, Kubo CH, Santos R. The influence of
ultrasound on the retention of cast posts cemented
with different agents. Int Endod J 2001: 34: 93–99.
157
Park
210. Hauman CHJ, Chandler NP, Purton DG. Factors
influencing the removal of posts. Int Endod J 2003:
36: 687–690.
211. Bergeron BE, Murchison DF, Schindler WG, Walker
WA. Effect of ultrasonic vibration and various sealer
and cement combinations on titanium post removal.
J Endod 2001: 27: 13–17.
212. Lindemann M, Yaman P, Dennison JB, Herrero AA.
Comparison of the efficiency and effectiveness of
various techniques for removal of fiber posts. J Endod
2005: 31: 520–522.
213. Warren SR, Gutmann JL. Simplified method for
removing intraradicular posts. J Prosthet Dent 1979:
42: 353–356.
214. Castrisos T, Abbott PV. A survey of methods used for
post removal in specialist endodontic practice. Int
Endod J 2002: 35: 172–180.
215. Braga NM, Silva JM, Carvalho-Júnior JR, Ferreira RC,
Saquy PC, Brito-Júnior M. Comparison of different
ultrasonic vibration modes for post removal. Braz Dent
J 2012: 23: 49–53.
216. Smith BJ. Removal of fractured posts using ultrasonic
vibration: an in vivo study. J Endod 2001: 27:
632–634.
217. Glick DH, Frank AL. Removal of silver points and
fractured posts by ultrasonics. J Prosthet Dent 1986:
55: 212–215.
218. Johnson WT, Leary JM, Boyer DB. Effect of ultrasonic
vibration on post removal in extracted human
premolar teeth. J Endod 1996: 22: 487–488.
219. Altshul JH, Marshall G, Morgan LA, Baumgartner JC.
Comparison of dentinal crack incidence and of
post removal time resulting from post removal by
ultrasonic or mechanical force. J Endod 1997: 23:
683–686.
220. Abbott PV. Incidence of root fractures and methods
used for post removal. Int Endod J 2002: 35: 63–67.
221. Dominici JT, Clark S, Scheetz J, Eleazer PD. Analysis
of heat generation using ultrasonic vibration for post
removal. J Endod 2005: 31: 301–303.
222. Horan BB, Tordik PA, Imamura G, Goodell GG.
Effect of dentin thickness on root surface temperature
of teeth undergoing ultrasonic removal of posts.
J Endod 2008: 34: 453–455.
223. Chee W, Aloum A. Restoration of the anterior maxilla
after thermal trauma as a sequela to post removal: a
clinical report. J Prosthet Dent 2011: 106: 141–144.
224. Lipski M, Debicki M, Drozdzik A. Effect of different
water flows on root surface temperature during
ultrasonic removal of posts. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2010: 110: 395–400.
225. Ettrich CA, Labossière PE, Pitts DL, Johnson JD. An
investigation of the heat induced during ultrasonic
post removal. J Endod 2007: 33: 1222–1226.
226. McGuigan MB, Louca C, Duncan HF. Clinical
decision-making after endodontic instrument fracture.
Br Dent J 2013: 214: 395–400.
227. Romeed SA, Dunne SM. The impact of fractured
endodontic file removal on vertical root fracture
158
resistance: three-dimensional finite element analysis.
Eur J Prosthodont Restor Dent 2012: 20: 86–91.
228. Gerek M, Başer ED, Kayahan MB, Sunay H, Kaptan
RF, Bayırlı G. Comparison of the force required to
fracture roots vertically after ultrasonic and Masserann
removal of broken instruments. Int Endod J 2011: 45:
429–434.
229. Nevares G, Cunha RS, Zuolo ML. Success rates for
removing or bypassing fractured instruments: a
prospective clinical study. J Endod 2012: 38: 442–
444.
230. Gencoglu N, Helvacioglu D. Comparison of the
different techniques to remove fractured endodontic
instruments from root canal systems. Eur J Dent 2009:
3: 90–95.
231. Shahabinejad H, Ghassemi A, Pishbin L, Shahravan A.
Success of ultrasonic technique in removing fractured
rotary nickel–titanium endodontic instruments from
root canals and its effect on the required force for root
fracture. J Endod 2013: 39: 824–828.
232. Ruddle CJ. Nonsurgical retreatment. J Endod 2004:
30: 827–845.
233. Ward JR, Parashos P, Messer HH. Evaluation of an
ultrasonic technique to remove fractured rotary
nickel–titanium endodontic instruments from root
canals: clinical cases. J Endod 2003: 29: 764–767.
234. Ward JR, Parashos P, Messer HH. Evaluation of an
ultrasonic technique to remove fractured rotary
nickel–titanium endodontic instruments from root
canals: an experimental study. J Endod 2003: 29:
756–763.
235. Nehme WB. Elimination of intracanal metallic
obstructions by abrasion using an operational
microscope and ultrasonics. J Endod 2001: 27:
365–367.
236. Shearer J, McManners J. Comparison between the use
of an ultrasonic tip and a microhead handpiece in
periradicular surgery: a prospective randomised trial.
Br J Oral Maxillofac Surg 2009: 47: 386–388.
237. Tsesis I, Rosen E, Schwartz-Arad D, Fuss Z.
Retrospective evaluation of surgical endodontic
treatment: traditional versus modern technique. J
Endod 2006: 32: 412–416.
238. Tsesis I, Faivishevsky V, Kfir A, Rosen E. Outcome of
surgical endodontic treatment performed by a modern
technique: a meta-analysis of literature. J Endod 2009:
35: 1505–1511.
239. Taschieri S, Del Fabbro M, Testori T, Francetti L,
Weinstein R. Endodontic surgery with ultrasonic
retrotips: one-year follow-up. Oral Surg Oral Med
Oral Radiol Endod 2005: 100: 380–387.
240. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S.
Outcome of endodontic surgery: a meta-analysis of the
literature—part 1: comparison of traditional root-end
surgery and endodontic microsurgery. J Endod 2010:
36: 1757–1765.
241. Bernabé PFE, Gomes-Filho JE, Bernabé DG, Nery
MJ, Otoboni-Filho JA, Dezan-Jr E, Cintra LTA.
Sealing ability of MTA used as a root end filling

material: effect of the sonic and ultrasonic
condensation. Braz Dent J 2013: 24: 107–110.
242. Lin CP, Chou HG, Kuo JC, Lan WH. The quality of
ultrasonic root-end preparation: a quantitative study.
J Endod 1998: 24: 666–670.
243. Camargo Villela Berbert FL, de Faria NB Jr,
Tanomaru-Filho M, Guerreiro-Tanomaru JM,
Bonetti-Filho I, de Toledo Leonardo R, Marcantonio
RA. An in vitro evaluation of apicoectomies and
retropreparations using different methods. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2010: 110:
e57–e63.
244. Gagliani M, Taschieri S, Molinari R. Ultrasonic root-
end preparation: influence of cutting angle on the
apical seal. J Endod 1998: 24: 726–730.
245. von Arx T, Walker WA 3rd. Microsurgical instruments
for root-end cavity preparation following apicoectomy:
a literature review. Endod Dent Traumatol 2000: 16:
47–62.
246. Bernardes RA, de Moraes IG, Garcia RB. Evaluation of
apical cavity preparation with a new type of ultrasonic
diamond tip. J Endod 2007: 33: 484–487.
247. Engel TK, Steiman HR. Preliminary investigation of
ultrasonic root end preparation. J Endod 1995: 21:
443–445.
248. Fabiani C, Franco V, Covello F, Brambilla E, Gagliani
MM. Removal of surgical smear layer. J Endod 2011:
37: 836–838.
249. Gutmann JL, Pitt Ford TR. Management of the
resected root end: a clinical review. Int Endod J 1993:
26: 273–283.
250. Craig KR, Harrison JW. Wound healing following
demineralization of resected root ends in periradicular
surgery. J Endod 1993: 19: 339–347.
251. Violich DR, Chandler NP. The smear layer in
endodontics—a review. Int Endod J 2010: 43: 2–15.
252. Yildirim T, Er K, Taşdemir T, Tahan E, Buruk K,
Serper A. Effect of smear layer and root-end cavity
thickness on apical sealing ability of MTA as a root-end
filling material: a bacterial leakage study. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2010: 109:
e67–e72.
253. Rodríguez-Martos R, Torres-Lagares D. Evaluation of
apical preparations performed with ultrasonic diamond
Ultrasonics in endodontics
and stainless-steel tips at different intensities using
a scanning electron microscope in endodontic
surgery. Med Oral Patol Oral Cir Bucal 2012: 17:
e988–e993.
254. von Arx T, Kunz R, Schneider AC, Bürgin W, Lussi A.
Detection of dentinal cracks after root-end resection:
an ex vivo study comparing microscopy and endoscopy
with scanning electron microscopy. J Endod 2010: 36:
1563–1568.
255. Layton CA, Marshall JG, Morgan LA, Baumgartner
JC. Evaluation of cracks associated with ultrasonic
root-end preparation. J Endod 1996: 22: 157–160.
256. Gray G, Hatton J, Holtzmann D, Jenkins D, Nielsen
C. Quality of root-end preparations using ultrasonic
and rotary instrumentation in cadavers. J Endod 2000:
26: 281–283.
257. Del Fabbro M, Tsesis I, Rosano G, Bortolin M,
Taschieri S. Scanning electron microscopic analysis of
the integrity of the root-end surface after root-end
management using a piezoelectric device: a cadaveric
study. J Endod 2010: 36: 1693–1697.
258. Beling KL, Marshall JG, Morgan LA. Evaluation of
cracks associated with ultrasonic root-end preparation
of gutta-percha filled canals. J Endod 1997: 23:
323–326.
259. Morgan LA, Marshall JG. A scanning electron
microscopic study of in vivo ultrasonic root-end
preparations. J Endod 1999: 25: 567–570.
260. Rainwater A, Jeansonne BG, Sarkar N. Effects of
ultrasonic root-end preparation on microcrack
formation and leakage. J Endod 2000: 26: 72–75.
261. Rosales-Leal JI, Olmedo-Gaya V, Vallecillo-Capilla M,
Luna-del Castillo JDD. Influence of cavity preparation
technique (rotary vs. ultrasonic) on microleakage
and marginal fit of six end-root filling materials.
Med Oral Patol Oral Cir Bucal 2011: 16: e185–
e189.
262. Brent PD, Morgan LA, Marshall JG. Evaluation of
diamond-coated ultrasonic instruments for root-end
preparation. J Endod 1999: 25: 672–675.
263. Navarre S, Steiman H. Root-end fracture during
retropreparation: a comparison between zirconium
nitride-coated and stainless-steel microsurgical
ultrasonic instruments. J Endod 2002: 28: 330–332.
159