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Currently, although ultrasonics (US) is used in dentistry for therapeutic and diagnostic applications as well as for cleaning of instruments before sterilization, its main use is for scaling and root planing of teeth and in root canal therapy, both for orthograde and retrograde therapy. Both in conventional and surgical treatments, US in endodontics has enhanced quality of clinical procedures and represents an important adjunct in the treatment of difficult cases. More precisely it has become increasingly more useful in applications such as gaining access to canal openings, cleaning and shaping, obturation of root canals, removal of intracanal materials and obstructions, and endodontic surgery. This review of the literature aims at presenting the numerous advantages of US in surgical endodontics and emphasizes its application in a modern-day endodontic practice.
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Ultrasonics in endodontic surgery: a review of the literature
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               Ultrasonics in endodontic surgery:
               a review of the literature




                                                                                                               i
                                                                                                             al
                                                                                                           on
               Gianfranco De Paolis, DDS, PhD                                tion, which converts electromagnetic energy into me-
               Valentina Vincenti, DDS                                       chanical energy. A stack of magnetostrictive metal strips
               Matteo Prencipe, DDS                                          in a handpiece is subjected to a standing and alternating
               Valerio Milana, DDS                                           magnetic field, as a result of which vibrations are produced.
               Gianluca Plotino, DDS, PhD                                    The second method is based on the piezoelectric princi-




                                                                                                         zi
                                                                             ple, in which a crystal is used that changes dimension when
               Dentists, private practice in Rome, Italy                     an electrical charge is applied. Deformation of this crys-
                                                                             tal is converted into mechanical oscillation without pro-




                                                                                         a
               Corresponding author:                                         ducing heat (1).
               Dott. Gianluca Plotino                                        In the last decade piezoelectric units have become the
               Via Eleonora, Duse 22




                                                                                      rn
                                                                             most common ultrasonic devices in dentistry. They have
               00197 Rome, Italy                                             some advantages compared with earlier magnetostrictive
               Tel.: 3396910098                                              units because they offer more cycles per second, 40 ver-
               E-mail: endo@gianlucaplotino.com                              sus 24 kHz. The tips of these units work in a linear, back-




                                                                             te
                                                                             and-forth, “piston-like” motion, which is ideal for en-
                                                                             dodontics. Lea et al. (9) demonstrated that the position
                                                                             of nodes and antinodes of an unconstrained and unloaded
                                                                             endosonic file activated by a 30-kHz piezon generator was
               Summary
                                                                    In       along the file length. As a result the file vibration dis-
               Ultrasonics in endodontic surgery: a review of the liter-
                                                                             placement amplitude does not increase linearly with in-
               ature.
                                                                             creasing generator power. This applies in particular when
               Currently, although ultrasonics (US) is used in dentistry     “troughing” for hidden canals or when removing posts and
                                                                             separated instruments. In addition, this motion is ideal in
                                                       ni
               for therapeutic and diagnostic applications as well as for
               cleaning of instruments before sterilization, its main use    surgical endodontics when creating a preparation for a ret-
               is for scaling and root planing of teeth and in root canal    rograde filling. A magnetostrictive unit, on the other hand,
               therapy, both for orthograde and retrograde therapy.          creates more of a figure eight (elliptical) motion, which is
                                             io


               Both in conventional and surgical treatments, US in en-       not ideal for either surgical or nonsurgical endodontic use.
               dodontics has enhanced quality of clinical procedures         In endodontic surgery, for example, this characteristic does
               and represents an important adjunct in the treatment of       not allow a precise cut of a cavity. The magnetostrictive units
                                    iz



               difficult cases. More precisely it has become increas-        also have the disadvantage that the stack generates heat,
               ingly more useful in applications such as gaining access      thus requiring adequate cooling (1). Once again, this over-
               to canal openings, cleaning and shaping, obturation of        heating is not desiderable in surgical endodontics.
               root canals, removal of intracanal materials and ob-
                      Ed




                                                                             In dentistry ultrasonics (US) or ultrasonic instrumentation
               structions, and endodontic surgery. This review of the        was first introduced to for cavity preparations (10,11), us-
               literature aims at presenting the numerous advantages         ing an abrasive slurry. Although the technique received fa-
               of US in surgical endodontics and emphasizes its appli-
                                                                             vorable comments (12,13), it never became popular, be-
               cation in a modern-day endodontic practice.
                                                                             cause it had to compete with the much more effective and
               Key words: endodontics, surgery, ultrasonics.
                                                                             convenient instruments, i.e. the burs mounted on high-
                                                                             speed handpieces (14). However, a different application
         IC




                                                                             was introduced in 1955, when Zinner (15) reported on the
                                                                             use of an ultrasonic instrument to remove deposits from
                                                                             the tooth surface. This was improved upon by Johnson and
               Introduction                                                  Wilson (16), and the ultrasonic scaler became an estab-
  C




                                                                             lished tool in the removal of dental calculus and plaque.
               In order to understand the basic concepts of the use of ul-   Currently, although US is used in dentistry for therapeu-
               trasonics (US) in dentistry, it must be underlined that ul-   tic and diagnostic applications as well as for cleaning of
               trasound is sound energy with a frequency above the range     instruments before sterilization, its main use is for scal-
©




               of human hearing, which is 20 kHz. In dentistry the range     ing and root planing of teeth and in root canal therapy, both
               of frequencies employed in the first ultrasonic units was     for surgical and non-surgical approach. (1,17,18). More re-
               between 25 and 40 kHz (1). Later, low-frequency ultrasonic    cently, the concept of minimally invasive dentistry (19,20)
               handpieces operating from 1 to 8 kHz were developed (2,3).    and the desire for preparations with small dimensions has
               This low-frequence devices were found to produce low-         stimulated new approaches in cavity design and tooth-cut-
               er shear stresses (4), thus causing less alteration to the    ting concepts, including ultrasound for cavity preparation
               tooth surface (5). Currently, there are two basic methods     (21).
               of producing ultrasound (6,7,8). The first is magnetostric-   The concept of using US in endodontics was first introduced

               6                                                                                     Annali di Stomatologia 2010; I (2): 6-10
0373 3 Ultrasonic_DePaolis:-        30-11-2010        18:56    Pagina 7




               Ultrasonics in endodontic surgery: a review of the literature


               by Richman (22) in 1957. However, it was not until Mar-           ing parallel to the canal, difficult access to the root end,
               tin et al. (23,24,25) demonstrated the ability of ultrasoni-      and risk of lingual perforation of the root. Furthermore, the
               cally activated K-type files to cut dentin that this applica-     inability to prepare to a sufficient depth, thus compromising
               tion found common use in the preparation of root canals           retention of the root-end filling material, means that the root-
               before filling andalso obturation. The term endosonics was        end resection procedure requires a longer cutting bevel,




                                                                                                                   i
               coined by Martin and Cunningham (26,27) and was de-               thus exposing more dentinal tubules and isthmus tissue,




                                                                                                                 al
               fined as the ultrasonic and synergistic system of root canal      of which the latter is difficult to remove. The development
               instrumentation and disinfection. The most frequent ap-           of ultrasonic and sonic retrotips has revolutionized root-
               plications of US in endodontics are the following. (i) Ac-        end therapy, improving the surgical procedure with better
               cess refinement, finding orifices and calcified canals, and       access to the root end, resulting in better canal prepara-




                                                                                                               on
               removal of attached pulp stones. (ii) Removal of intracanal       tion (44,45). Ultrasonic retrotips come in a variety of shapes
               obstructions (separated instruments, root canal posts, sil-       and angles, thus improving some steps during the surgi-
               ver points, and fractured metallic posts). (iii) Root canal       cal procedures (46,47).
               preparation using ultrasonically activated k-files. (iv) Root     Probably, the most relevant clinical advantages are the en-
                                                                                 hanced access to root-ends in a limited working space. This




                                                                                                             zi
               canal irrigation with an increased action of irrigating so-
               lutions, due to cavitation and microstreaming action. (v) Ul-     leads to a smaller osteotomy for surgical access because
               trasonic condensation of gutta-percha. (vi) Placement of          of the advantage of using various angulations and the small
               calcium hydroxide and mineral trioxide aggregate (MTA).           size of the retrotips (48). However, a number of studies com-




                                                                                             a
               (vii) Surgical endodontics: root-end cavity preparation and       pared root-end preparations made with microsurgical tips
               refinement and placement of root-end obturation materi-           to those made with burs. They demonstrated additional ad-




                                                                                          rn
               al                                                                vantages of this technique, such as deeper and more con-
               The aim of the present literature review is to analyze and        servative cavities that follow the original path of the root
               discuss the use of US in surgical endodontics, focusing at-       canal more closely (49,50,51,52,53,54). A better-centered
               tention mainly of the advantages of US-activated instru-          root-end preparation also lessens the risk of lateral per-




                                                                                 te
               ments for cavity preparation and refinement. Moreover the         foration. Furthermore, the geometry of the retrotip design
               use of US for the placement of root-end filling materials-        does not require a beveled root-end resection for surgical
               will also be addressed.                                           access, thus decreasing the number of exposed dentinal
                                                                       In        tubules (55,56,57) and minimizing apical leakage
                                                                                 (58,59,60,61). They also enable the removal of isthmus tis-
               The use of ultrasonics in Surgical Endodontics                    sue present between two canals within the same root
                                                                                 (62,63,64). It is considered a time-saving technique that
               In the past decades root-end cavities have traditionally been     seems to have a lower failure rate.
                                                          ni
               prepared by means of small round or inverted cone burs            More recently, the cleaning effect and the cutting ability of
               in a micro-handpiece. In the mid-1980s, standardized in-          ultrasonic retrotips have been described as satisfactory by
               struments and aluminum oxide ceramic pins were intro-             many authors (65,66). Furthermore, US produced less
               duced for retrograde filling (28), but that system could not      smear layer in a retro-end cavity compared to a slow-speed
                                                 io


               be used in cases with limited working space or in teeth with      handpiece (67). Moreover, the refinement of cavity mar-
               large oval canals. Soon after sonically or ultrasonically driv-   gins that were obtained with the ultrasonic tips may pos-
               en microsurgical retrotips became commercially available          itively affect the delivery of materials into the cavities and
                                       iz



               in the early 1990s (29,30,31,32), this new technique of ret-      enhance their seal (68,69,70), even if cavities prepared with
               rograde root canal instrumentation has become rapidly pop-        erbium:YAG lasers have been shown to produce signifi-
               ular and been established as an essential adjunct in peri-        cantly lower microleakage than ultrasonic preparations (71).
                      Ed




               radicular surgery (33,34). However, the cutting properties        Amongst the possibile iatrogenic errors, in a study by Walm-
               of the retrotips at that time were limited and seemed to be       sley et al. (72) the breakage of ultrasonic root-end prepa-
               dependent on loading, power setting, and orientation of the       ration tips was investigated and attributed to the design of
               tip to the long axis of the handpiece (35,36). Moreover in        the tip. Increased angulation of retrotips increases the trans-
               some retrotips, cooling of the working tip was insufficient,      verse oscillation and decreases the longitudinal oscillation,
               and dentin and bone were at risk of being overheated.             putting the greatest strain at the bend of the instrument.
               However, the technique was promising and led to signif-           The authors suggested reducing the angulation and in-
         IC




               icant improvement in the instruments, which have signif-          creasing the dimensions of the tip to resist breakage. This
               icantly enhanced the treatment outcome in apicoectomy             may be true, but a straighter design will restrict access and
               with retrofilling (37). As the prognosis of endodontic sur-       a thicker instrument prevents instrumentation of isthmus-
               gery is highly dependent on good obturation and sealing           es. A controversial issue with sonic or ultrasonic root-end
  C




               of the root canal, an optimal cavity preparation is an es-        preparation is the formation of cracks or microfractures and
               sential prerequisite for an adequate root-end filling after       its implications for healing success (73,74). Some studies
               apicoectomy (38,39). The first root-end preparation using         indicated that this was a possible drawback
               modified ultrasonic inserts following an apicoectomy is at-       (75,76,77,78,79). Other studies, however, disputed these
©




               tributed to Bertrand et al. (40). Others followed, but it was     findings and did not report a higher prevalence of mi-
               not until 1987 that Flath and Hicks (41) further reported         crofractures (80,81,82,83,84,85,86,87,88,). Khabbaz et al.
               on the use of ultrasonics and sonics for root-end cavity          (53) found that cracks did not correlate directly with the sur-
               preparation.                                                      face area of the root-end surfaces but rather with the type
               One of the reason for the success of US retrotips is due          of retrotip used. Preparation with smooth stainless steel
               to the fact that conventional root-end cavity preparation us-     ultrasonic tips produced fewer intradentin cracks than di-
               ing rotary burs in a micro-handpiece is faced with sever-         amond-coated stainless steel ultrasonic tips and sonic di-
               al problems (42,43), such as a cavity preparation not be-         amond-coated tips. It is recommended that the ultrason-

               Annali di Stomatologia 2010; I (2): 6-10                                                                                        7
0373 3 Ultrasonic_DePaolis:-         30-11-2010     18:56      Pagina 8




               G. De Paolis et al.


               ic unit be set at medium power and the cavities be prepared       in open and diverging apices, but it can also be used to
               to a depth of 2.5-3 mm (89). This depth allows for a min-         put the material in root-end cavities, in perforations, and
               imum thickness of material that can still provide an effective    especially in perforations of the floor of the pulp chamber.
               apical seal (90). The cavity walls should be parallel and fol-
               low the anatomic outline of the pulpal space (91). It has




                                                                                                                       i
               also been suggested that root-end cavities should be ini-         References




                                                                                                                     al
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                                                                                                                   on
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                                                                                              a
                                                                                  5. Layton CA, Marshall JG, Morgan LA, Baumgartner JC. Eval-
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                                                                                           rn
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                                               io

                                                                                     (Progress report). J Am Dent Assoc. 1954;50:414-417.
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         IC




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  C




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©




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               8                                                                                             Annali di Stomatologia 2010; I (2): 6-10
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               Ultrasonics in endodontic surgery: a review of the literature


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                                                                                                                      on
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                                                                                                rn
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                                                  io

                     2000;26:444-446.                                                     dod Dent Traumatol. 1999;15:265-268.
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                                        iz



                     ration with new devices. J Endod. 1987;13:546-549.                   78.
               42.   von Arx T, Walker WA. Microsurgical instruments for root-end     66. Sultan M, Pitt-Ford TR. Ultrasonic preparation and obtura-
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                       Ed




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