Review Article
Ultrasonics in Endodontics: A Review of the Literature
Gianluca Plotino, DDS,* Cornelis H. Pameijer, DMD, DSc, PhD,† Nicola Maria Grande, DDS,*
and Francesco Somma, MD, DDS*
Abstract
During the past few decades endodontic treatment has
benefited from the development of new techniques and
equipment, which have improved outcome and predict-
ability. Important attributes such as the operating mi-
croscope and ultrasonics (US) have found indispensable
applications in a number of dental procedures in peri-
odontology, to a much lesser extent in restorative den-
tistry, while being very prominently used in endodon-
tics. US in endodontics has enhanced the quality of
treatment and represents an important adjunct in the
treatment of difficult cases. Since its introduction, US
has become increasingly more useful in applications
such as gaining access to canal openings, cleaning and
shaping, obturation of root canals, removal of intraca-
nal materials and obstructions, and endodontic surgery.
This comprehensive review of the literature aims at
presenting the numerous uses of US in clinical endo-
dontics and emphasizes the broad applications in a
modern-day endodontic practice. (J Endod 2007;33:
81–95)
Key Words
Endodontics, innovations, ultrasonics
From the *Department of Endodontics, Catholic University
of Sacred Heart, Rome, Italy; and the †School of Dental Med-
icine, University of Connecticut, Farmington, CT.
Address requests for reprints to Gianluca Plotino, DDS, Via
Eleonora Duse, 22– 00197 Rome, Italy. E-mail address:
gplotino@fastwebnet.it.
0099-2399/$0 - see front matter
Copyright © 2007 by the American Association of
Endodontists.
doi:10.1016/j.joen.2006.10.008
JOE — Volume 33, Number 2, February 2007
T he use of ultrasonics (US) or ultrasonic instrumentation was first introduced to
dentistry for cavity preparations (1–3) using an abrasive slurry. Although the tech-
nique received favorable reviews (4, 5), it never became popular, because it had to
compete with the much more effective and convenient high-speed handpiece (6).
However, a different application was introduced in 1955, when Zinner (7) reported on
the use of an ultrasonic instrument to remove deposits from the tooth surface. This was
improved upon by Johnson and Wilson (8), and the ultrasonic scaler became an
established tool in the removal of dental calculus and plaque. The concept of using US
in endodontics was first introduced by Richman (9) in 1957. However, it was not until
Martin et al. (10 –12) demonstrated the ability of ultrasonically activated K-type files to
cut dentin that this application found common use in the preparation of root canals
before filling and obturation. The term endosonics was coined by Martin and Cunning-
ham (13, 14) and was defined as the ultrasonic and synergistic system of root canal
instrumentation and disinfection.
Ultrasound is sound energy with a frequency above the range of human hearing,
which is 20 kHz. The range of frequencies employed in the original ultrasonic units was
between 25 and 40 kHz (15). Subsequently the so-called low-frequency ultrasonic
handpieces operating from 1 to 8 kHz were developed (16 –21), which produce lower
shear stresses (22), thus causing less alteration to the tooth surface (23).
There are two basic methods of producing ultrasound (24 –26). The first is mag-
netostriction, which converts electromagnetic energy into mechanical energy. A stack of
magnetostrictive metal strips in a handpiece is subjected to a standing and alternating
magnetic field, as a result of which vibrations are produced. The second method is
based on the piezoelectric principle, in which a crystal is used that changes dimension
when an electrical charge is applied. Deformation of this crystal is converted into
mechanical oscillation without producing heat (15).
Piezoelectric units have some advantages compared with earlier magnetostrictive units
because they offer more cycles per second, 40 versus 24 kHz. The tips of these units work in
a linear, back-and-forth, “piston-like” motion, which is ideal for endodontics. Lea et al. (27)
demonstrated that the position of nodes and antinodes of an unconstrained and unloaded
endosonic file activated by a 30-kHz piezon generator was along the file length. As a result the
file vibration displacement amplitude does not increase linearly with increasing generator
power. This applies in particular when “troughing” for hidden canals or when removing
posts and separated instruments. In addition, this motion is ideal in surgical endodontics
when creating a preparation for a retrograde filling. A magnetostrictive unit, on the other
hand, creates more of a figure eight (elliptical) motion, which is not ideal for either surgical
or nonsurgical endodontic use. The magnetostrictive units also have the disadvantage that the
stack generates heat, thus requiring adequate cooling (15).
Applications of US in Endodontics
Although US is used in dentistry for therapeutic and diagnostic applications as well
as for cleaning of instruments before sterilization (28), currently its main use is for
scaling and root planing of teeth and in root canal therapy (15, 28, 29). The concept of
minimally invasive dentistry (30, 31) and the desire for preparations with small dimen-
sions has stimulated new approaches in cavity design and tooth-cutting concepts, in-
cluding ultrasound for cavity preparation (32).
The following is a list of the most frequent applications of US in endodontics, which
will be reviewed in detail:
1. Access refinement, finding calcified canals, and removal of attached pulp
stones
Ultrasonics in Endodontics 81
Review Article
2. Removal of intracanal obstructions (separated instruments, root
canal posts, silver points, and fractured metallic posts)
3. Increased action of irrigating solutions
4. Ultrasonic condensation of gutta-percha
5. Placement of mineral trioxide aggregate (MTA)
6. Surgical endodontics: Root-end cavity preparation and refine-
ment and placement of root-end obturation material
7. Root canal preparation

Access Refinement, Finding Calcified Canals, and Removal of

Attached Pulp Stones
One of the challenges in endodontics is to locate canals, particu-
larly in cases in which the orifice has become occluded by secondary
dentin or calcified dentin secondary to the placement of restorative
materials or pulpotomies. With every access preparation in a calcified
tooth, there is the risk of perforating the root or, when incorrectly
performed, of complicating each subsequent procedure. A lack of a
straight-line access is arguably the leading cause of separation,
perforation, and the inability to negotiate files to the radiographic
terminus (33).
The introduction of the microscope, access burs, and US (34) has
greatly reduced these risks. Microscopic visualization and ultrasonic
instruments are a safe and effective combination to achieve optimal
results (35–37).
In difficult-to-treat teeth such as molars, US has proven to be useful
for access preparation, not only for finding canals, but also for reducing
the time and the predictability of the treatment (33, 34).
In conventional access procedures, ultrasonic tips are useful for
access refinement, location of MB2 canals in upper molars and acces-
sory canals in other teeth, location of calcified canals in any tooth, and
removal of attached pulp stones (35–37).
There are numerous variations of rotary access burs available;
however, one of the more important advantages of ultrasonic tips is that
they do not rotate, thus enhancing safety and control, while maintaining
a high cutting efficiency. This is especially important when the risk of
perforation is high.
The visual access and superior control that ultrasonic cutting tips
provide during access procedures make them a most convenient tool,
especially when treating difficult molars. When locating the MB2 canals
in upper molars, US is an excellent means for the removal of secondary
dentin on the mesial wall (Fig. 1). When searching for hidden canals,
one should remember that secondary dentin is generally whitish or Figure 1. The orifice of the second mesiobuccal canal (MB2) in an upper first
opaque, whereas the floor of the pulp chamber is darker and gray in molar was located (a) and enlarged (b). Dentine spur at the orifice was effec-
appearance. US works well when breaking through the calcification that tively eliminated with the use of a diamond-coated ultrasonic tip, thus permitting
easy location of the orifice of the canal.
covers the canal orifice. A troughing tip is a good choice for this task
(Fig. 2a,b). For these applications, bigger tips with a limited diamond-
coated extension should be used during the initial phase of removing cutting may cause an undesired modification of the anatomy of the pulp
calcification, interferences, materials, and secondary dentin, as they chamber.
offer maximum cutting efficiency and enhance control while working in
the pulp chamber (Fig. 2c,d). The subsequent phase of finding canal Removal of Intracanal Obstructions
orifices should be carried out with thinner and longer tips that facilitate Clinicians are frequently challenged by endodontically treated
working in deeper areas while maintaining clear vision (33, 34) (Fig. 2e). teeth that have obstructions such as hard impenetrable pastes, sepa-
The diamond-coated tips used in orthograde endodontic treat- rated instruments, silver points, or posts in their roots (41). If end-
ment (Fig. 2a– e) have shown significantly greater cutting efficiency odontic treatment has failed, these obstructions need to be removed to
than either stainless steel tips or zirconium nitride– coated tips, but they perform nonsurgical retreatment. Many instruments and techniques
have a tendency to break (38). Moreover, thinner diamond-coated tips have been reported (42, 43). They include appropriate burs (44);
seem to be able to transmit the oscillation of the ultrasonic unit more special forceps (45); ultrasonic instruments in direct or indirect con-
efficiently into dentin; this results in a more aggressive cutting action tact (46 – 49); peripheral filing techniques in the presence of solvents,
(39). Ultrasonic cutting seems to be significantly influenced by the chelators, or irrigants (50); microtube delivery using mechanical ad-
power setting (39), as larger fragments of dentin are removed at higher hesion techniques (51); and different kits and extractors (52–54).
power (40), and by the ultrasonic unit type used (39). Therefore, care Ultrasonic energy has proven effective as an adjunct in the removal
should be exercised while searching for canal orifices, as aggressive of silver points, fractured instruments, and cemented posts (55). It has

82 Plotino et al. JOE — Volume 33, Number 2, February 2007

 Review Article

Figure 2. (a) The BUC-1 is an example of diamond-coated spreader tip of medium length that can be used for gross dentin removal, moving access line angles, cutting
a groove in the mesial access wall to drop into MB2 canals, and quickly and carefully unroofing pulp chambers. (b) The BUC-3 is similar to the BUC-1 with a sharper
tip and a water port for increased washing and cooling of the operative site. It is used for chasing canals or for digging around a post or carrier-based obturator with
the objective to remove it. (c) This diamond-coated pear tip is used to find canals, remove coronal obstructions or restorative materials, or remove calcifications,
temporary and permanent cements, and posts. It creates a smooth, clean flat troughing groove that facilitates canal location. (d) This diamond-coated ball tip provides
fine cutting control when preparing a troughing groove and is less aggressive than the pear tip shown in c, yet it has the same clinical indications. (e) A classic spreader
tip with a diamond coating, which offers a side- as well as an end-cutting action. This is needed to flare the walls of a troughing groove in an axial direction. (f) A fine
spreader tip indicated for troughing and removal of broken instruments. (g) An extra-fine spreader tip used for extremely fine and deep troughing or removal of a
separated instrument in the middle or apical third of the canal. (h) A spreader tip designed for multiple uses such as instrument or silver point removal, troughing,
removal of calcifications, provisionals, cements, buildup materials, etc. (i) Vibrator tip specifically designed for post removal.

often been advocated for the removal of broken instruments because the
ultrasonic tips or endosonic files may be used deep in the root canal
system (56). Furthermore, the use of an ultrasonic endodontic device is
not restricted by the position of the fragment in the root canal or the
tooth involved (57).
The prognosis of these cases mainly depends on the preoperative
condition of the periapical tissues (58, 59). For this reason an attempt
to remove broken instruments should be undertaken in every case (60).
When these obstructions can be removed, successful treatment or re-
treatment generally occurs (61). If an instrument can be removed or
bypassed and the canal can be properly cleaned and filled, nonsurgical
endodontics is a more desirable and conservative approach (62). The
removal of an obstacle from a root canal must be performed with a
minimum of damage to the tooth and the surrounding tissues (44). Too
much destruction of tooth structure will complicate the restorative
phase and as a result will most likely decrease the overall prognosis.
Although it is possible to remove many fragments, a small number
cannot be removed because of limited access, despite the use of ultra-
sonic tips (63) (Fig. 2f,g). When the obstacle prevents access to the root
apex, adequate preparation, disinfection, and obturation of the entire
root canal system are not possible. Straight-line access is essential and
allows for maximum visibility of the metallic fragment (64). For that
reason, the use of magnification (dental operating microscope or
loupes) is essential, as it provides direct visualization with excellent
illumination, allowing instrumentation at high magnifications.
Separated Instruments
Management of a broken instrument requires an orthograde or a
surgical approach. The three orthograde approaches are (a) attempt to
remove the instrument; (b) attempt to bypass the instrument; and (c)
prepare and obturate to the fractured segment (65).
In most cases, removal of broken instruments from the root canal
is difficult and often hopeless (66). To date, no standardized procedure
for the safe removal of fractured instruments exists, although various
techniques and devices have been suggested (67, 68). These techniques
have shown only limited success, while often causing considerable dam-
age to the remaining root (61, 68). Complications as a result of these
techniques include excessive loss of root canal dentin, ledging, perfo-
ration, and extrusion of the fractured instrument fragment through the
apex (69). Therefore, many techniques cannot be used in narrow and
curved canals (61).
Over the years, different techniques have been proposed for the
removal of separated instruments from root canals (44, 57, 60, 63, 66,
70 –72). Recent advances in endodontics have led to the development
of techniques and devices designed specifically for the safe removal of
fractured instruments from deep within narrow curved root canals (73)
(Fig. 3). Ruddle (64, 71) proposed a technique for the removal of
broken instruments using Gates Glidden drills (size 3 or 4) to prepare
a circumferential “staging platform” at the coronal aspect of the ob-
struction (Fig. 4). Attention must be paid during preparation of a staging
platform, because a size 3 or 4 Gates Glidden may perforate or weaken
a root, for instance the mesial (74, 75) and distal root (76) of mandib-
ular molars, the distobuccal and mesiobuccal roots of maxillary molars
(77), and central and lateral mandibular incisors (77). Their use seems
safe in central and lateral maxillary incisors (77), maxillary and man-
dibular canines (77), and mandibular premolars (78, 79). The litera-
ture is controversial with regard to maxillary premolars because of their
particular anatomy (80 – 82).
Radiographic evaluation of the residual dentin thickness during
preparation of the platform can be misleading because of the inaccu-
racy of radiographic interpretation. Overestimation may lead to over-
preparation of the canal or root perforation (83). Recently, it has been
shown that preparation of staging platforms was best accomplished with
the use of modified LightSpeed files (84). The inability to see the instru-
ment with direct vision and the difficulty of creating a staging platform,
as well as the use of US in curved roots, has contributed to a lack of
success in removing fractured instruments under these circumstances
(57, 61, 63, 69, 84).
Root Canal Posts
Nonsurgical endodontic retreatment of teeth restored with intrara-
dicular posts continues to present a challenge because of the inherent

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Review Article
Figure 3. NiTi rotary instrument separated in the distobuccal canal of an upper
first molar (a). The fragment was removed using ultrasonic tips, and the root
canals were successfully negotiated to the apex (b) and cleaned, shaped, and
filled (c). The tooth was subsequently restored with two fiber-reinforced posts,
one in the palatal and one in the mesiobuccal canal, followed by a dual-cure
resin composite core buildup (c).
84 Plotino et al.
difficulties of removing posts without weakening, perforating, or frac-
turing the remaining root structure (85– 88). Many techniques and
instruments have been described to aid in the removal of posts (52, 85,
88 –94).
US has provided clinicians with a useful adjunct to facilitate
post removal with minimal loss of tooth structure and root damage
(48, 95–97). Many studies have focused on the removal of metallic
posts; however, retreatment of fiber-reinforced composite posts ce-
mented with adhesive systems presents a new challenge in cases in
which endodontic treatment has failed (98). Different bur kits have
been proposed to remove fiber posts (99, 100); however, the preser-
vation of maximum root structure requires the use of specific ultrasonic
Figure 4. Gates Glidden bur modified by cutting it at the maximum diameter
viewed from an apical (a) and lateral direction (b). This permits the prepara-
tion of a platform at the extruded portion of the fragment to be removed.
JOE — Volume 33, Number 2, February 2007

tips (Fig. 2h) and adequate magnification. The disruption of the com-
posite structure through the action of ultrasonic vibration seems to be
the most effective technique in fiber post removal (101). Esthetic white
posts are more difficult to remove because their color matches that of
dentin, whereas the black carbon fiber posts clearly contrast to dentin.
Removal is done in a dry field using a continuous stream of air with
direct vision of the ultrasonic tip and the coronal portion of the post,
alternated by air and water spray to clean the remnants of fibers and
dentin.
It is important that the entire composite material that was used in
the luting procedure be removed. If the adhesive procedure was done
well, removal of the tenaciously attached adhesive materials will be
difficult, and high magnification must be used to guide the ultrasonic tip
to selectively remove the attached composite material. If the ultrasonic
tip leaves behind gray streaks, it is a clear indication that resin compos-
ite or resin composite cement is still present.
The need of consuming fiber posts is based on the fact that the
viscoelastic nature of composite resin dampens vibrations and adsorbs
energy (102). Conductance of vibration forces within a post is propor-
tional to the square root of the modulus of elasticity of the post material
(103). Therefore, a fiber-reinforced composite post with a significantly
lower modulus of elasticity than stainless steel or titanium (104, 105)
conducts vibration less efficiently (97). Combining the low modulus of
elasticity of post materials with composite resin cements causes a
change in the effectiveness of US as an aid in post removal (97). Resin
cements are not friable and do not tend to produce microfractures due
to ultrasonic vibration (106). It was suggested that the absence of a
water spray seems to increase the action of US when applied to posts
cemented with resin cements, possibly because of the increase in heat
(107). This is helpful information, as it has been observed that the
capacity of adhesion of a resin cement, and consequently mechanical
retention, gradually reduces with the number of thermal cycles (108).
Several studies point to the fact that ultrasonic vibration of posts
facilitates their removal while conserving tooth structure and reducing
the possibility of fractures or root perforations (55, 86 – 88, 95, 102,
109). Several studies have demonstrated a reduction in tensile failure
loads of intraradicular-cemented posts after ultrasonic vibration (55,
86 – 88, 95, 102, 107, 109 –116). Other studies did not find a difference
Review Article
(97, 117, 118). Bergeron et al. (119) and Garrido et al. (107) sug-
gested that heat generation might have been responsible for the increase
in retention after ultrasonic vibration, as no water-cooling was used
during the procedure. As to the fiber-reinforced root canal posts,
Bergeron et al. (119) and Hauman et al. (97) further hypothesized that
the lower modulus of elasticity of the titanium compared with that of the
stainless steel may have been responsible for the ineffectiveness of US in
reducing post retention.
Using US involves the initial removal of restorative material(s) and
luting cement around the post, followed by application of the tip of an
ultrasonic instrument to the post (Fig. 5a– g). Ultrasonic energy is
transferred through the post and breaks down the cement until the post
loosens (107) (Fig. 5h). This method of post removal minimizes loss of
tooth structure and decreases the risk of tooth damage (48, 95, 97).
When removing a post, it is critical to break the seal between the
post and the tooth structure. It has been recommended to reduce the
extraradicular portion of the post to the same diameter as the intrara-
dicular portion (118) to reduce the necessary tension to remove it
(114). In some cases this can be accomplished with a surgical-length
round bur, a technique not without danger. Once trephining around the
post has been done, a basic spreader tip placed in the trough is a good
choice (Fig. 2h). This will further break down the integrity of the cement
or resin, usually resulting in loosening of the post. Alternatively, the
ultrasonic tip can be placed on the post or on a hemostat that is clamped
to the post. The tip should not be too thin, because small-diameter
ultrasonic instruments are weak and more predisposed to breakage,
especially when they are used for a long time on a resistant material (Fig.
2i). On the other hand, the tip should not be too large, because it must
be kept in intimate contact with the post when it is moved counterclock-
wise around the post (98) (Fig. 2a,b). Usually, the ultrasonic unit is set
to the maximum power level (97, 107, 111, 114, 119, 120). Because
this generates heat, especially over longer periods of application, cool-
ing with a water spray is of the essence. When heat is transferred to a
metal post, it can be transferred to the periodontal ligament, causing
damage (121), even with the use of a piezoelectric ultrasonic handpiece
(122). There is in vitro evidence that application of US to metal posts,
even with adequate water-spray cooling (120), can lead to rapid in-

Figure 5. Preoperative image (a) and radiograph (b) of a mandibular first molar with three gold cast posts and cores and full-crown coverage. The patient presented
with pain and swelling. The preoperative diagnostic radiograph revealed signs of radiolucency in the furcal area toward the mesial root. The metal-ceramic crown
was sectioned (c) and removed (d), and the gold cast posts were separated to facilitate their removal (e, f). The three posts were removed (g) by vibrating with an
ultrasonic tip to disrupt the cement seal (h). This clinical image revealed two perforations in the mesial root canal (h). Perforations were repaired using gray MTA
compacted with an ultrasonic tip (i). Root canals were filled with gutta-percha and sealer (l), and the coronal portions of the mesial canals were further filled with
MTA to enhance the seal of the perforations (m). Postendodontic preprosthetic restoration was performed using a fiber-reinforced post in the distal canal and a
dual-cure resin composite buildup material (n).

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Review Article
creases in temperature of the root surface, causing damage to the peri-
odontal ligament (122, 123).
The relative ease of removing prefabricated parallel posts with the
use of US is probably related to their design, as they do not adapt well to
the coronal third of most root canals. This allows for easy breakdown of
the cement in the coronal third and subsequent shifting of the fulcrum
point toward the apical end of the post. As the fulcrum point shifts
apically, the ultrasonic vibrations start to move the post about this point
and within the space created in the coronal third. This movement helps
to break down the cement/post interface toward the apical end of the
post in conjunction with breakdown within the cement itself.
In cases in which the post has a tight fit with adequate length and
diameter, and with limited access to the coronal portion, the effect of US
alone may be limited or even ineffective. In these situations the clinician
has to consider other treatment options (118).
In a clinical study by Smith (112), the mean time required to
dislodge posts with an ultrasonic instrument was approximately one-
quarter of that reported for in vitro studies (97). This may be explained
in that, in a clinical setting, the reason for removing posts is due to
infected root canals frequently caused by coronal leakage, leading to
breakdown of the cement, retaining both the coronal restoration and
the post. In clinical practice posts should therefore be easier to remove
than under laboratory conditions (97). Clinically, after removing all
circumferential restorative materials, the majority of posts can be safely
and successfully removed within approximately 10 minutes (102, 110).
However, certain posts resist removal, even after 10 minutes of ultra-
sonic activation (98).
Silver Points and Fractured Metallic Posts
Several studies have shown that retrieval of silver cones can be
performed with traditional techniques using hand instruments and par-
ticular devices and extractors (45, 50, 51, 66, 124, 125).
Other techniques utilize ultrasonic energy in cases of intracanal
obstruction and consume the obstruction with particular ultrasonic
tips. This predominantly applies to silver points inside canals, which
cannot be bypassed by conventional methods (62, 126).
The traditional clinical procedure to remove root canal posts or
silver points fractured at the orifice consists of exposing the coronal part
of the obstacle by cutting an estimated 2.0-mm trough around the ob-
stacle with a fine diamond bur. The tip of an ultrasonic unit (Fig. 2h) is
then applied to the side of the post fragment at full power with water
irrigation. Ultrasonic vibration is applied for periods of a few seconds
followed by drying with compressed air. This should lead to dislodge-
ment of the fragment of the post, which can then be removed with a fine
forceps (47, 112, 127).
When an obstruction allows for limited access to the coronal por-
tion of the point, a more conservative approach would be to try to
consume it instead of consuming the surrounding dentin (62, 126).
An important point to realize when removing silver points is that
one is dealing with a very soft material. Any misdirection of a bur can
sever the point, complicating the case even further. US has proven to be
very helpful in the removal of these points. Simply trough around the
silver point with an ultrasonic spreader tip (Fig. 2f,g) and carefully
eliminate dentin while following the long axis, taking care not to cut the
point. The space created around the silver point will usually loosen the
silver point, which can then be removed with a Steiglitz forceps or
hemostat. At all times, the use of intraoral radiographs is recommended
to confirm the position and the remaining length of the obstruction, as
well as the thickness of canal walls (47, 64). The time required for
removal of a post or silver point is influenced by the nature of the
obstruction, its diameter, and location. Semiprecious metals take more
86 Plotino et al.
time than precious metals. Large-diameter posts are more time con-
suming compared with narrow ones (62).
Increased Action of Irrigating Solutions
The effectiveness of irrigation relies on both the mechanical
flushing action and the chemical ability of irrigants to dissolve tissue
(128, 129). Furthermore, the flushing action of irrigants helps to re-
move organic and dentinal debris and microorganisms from the canal
(130). The flushing action from syringe irrigation is relatively weak and
dependent not only on the anatomy of the root canal but also on the
depth of placement and the diameter of the needle (128, 131, 132). It
has been shown that irrigants can only progress 1 mm beyond the tip of
the needle (133). An increase in volume does not significantly improve
their flushing action and efficacy in removing debris (134, 135). In
larger apical canals, the debridement and disinfection of canals is im-
proved (128). However, thorough cleaning of the most apical part of
any preparation remains difficult (136). Using thinner needles (30
gauge) may facilitate reaching the apical area directly. Although con-
clusive evidence is still lacking, the introduction of slim irrigating nee-
dles with a safety tip placed to working length or 1 mm short of it is a
promising approach to improve irrigant efficacy.
The only effective way to clean webs and fins is through movement
of the irrigation solution (137), as they cannot be mechanically cleaned
(138). US is a useful adjunct in cleaning these difficult anatomical
features. It has been demonstrated that an irrigant in conjunction with
ultrasonic vibration, which generates a continuous movement of the
irrigant, is directly associated with the effectiveness of the cleaning of the
root canal space (22, 137–142).
Acoustic streaming, as described by Ahmad et al. (140), has been
shown to produce sufficient shear forces to dislodge debris in instru-
mented canals. When files were activated with ultrasonic energy in a
passive manner, acoustic streaming was sufficient to produce signifi-
cantly cleaner canals compared with hand filing alone. Similarly,
Jensen et al. (143) recommended a vibrating file of small size subjected
to a high power setting, as smaller files will be less likely to contact the
canal walls.
The flushing action of irrigants may be enhanced by using US (15,
132, 140, 144, 145). This seems to improve the efficacy of irrigation
solutions in removing organic and inorganic debris from root canal
walls (12, 129, 132, 142, 143, 145–158). A possible explanation for the
improved action is that a much higher velocity and volume of irrigant
flow is created in the canal during ultrasonic irrigation (129).
The tissue-dissolving capability of solutions with a good wetting
ability may be enhanced by US if the pulp tissue remnants and/or smear
layer are wetted completely by the solution and become subject to the
ultrasonic agitation (145, 159). US creates both cavitation and acoustic
streaming. The cavitation is minimal and is restricted to the tip (160). The
acoustic streaming effect, however, is significant (161). In fact, the irrigant
is activated by the ultrasonic energy imparted from the energized instru-
ments, producing acoustic streaming and eddies (15, 140, 141).
US can also improve disinfection of root canals (148, 149, 162–166),
probably because organic tissues entering the streaming field that is
generated are disrupted, as proposed by Walmsley (24). Ahmad (167)
confirmed that ultrasonically activated files produced streaming pat-
terns close to the file, continuously moving irrigants around, thereby
producing shear stress, which can damage biological cells, as stated by
Williams (168).
Although the number of surviving colonies was less when ultra-
sonic activation was used, no technique was able to ensure complete
disinfection (130, 143, 161, 169, 170). Cameron (171) postulated that
there is a synergistic effect between sodium hypochlorite (NaOCl) and
US. The ability of NaOCl to dissolve collagen is enhanced with heat
JOE — Volume 33, Number 2, February 2007

(172); therefore, the effect of heat on the irrigant produced by ultra-
sonic action plays an important role (15, 173).
The effectiveness of hand syringe irrigation in narrow canals has
been questioned by several investigators (145, 174 –178). Narrow ca-
nals may also compromise the effectiveness of ultrasonic irrigation
(15, 144, 179), and when sonic or ultrasonic files are used in small,
curved canals, they may bind, thus restricting their vibratory motion and
cleaning efficiency (180).
For irrigating solutions to be effective, they have to be in direct
contact with a surface (181). In small-diameter roots, irrigating solu-
tions have difficulty reaching the apex of the tooth and therefore are least
influenced by activated irrigation (166, 182). Furthermore, van der
Sluis et al. (183) have postulated that ultrasonic irrigation should be
more effective in removing debris from root canals with greater tapers.
It appeared to be important to apply the ultrasonic instrument after
canal preparation had been completed (184). Furthermore, a freely
oscillating instrument will cause more ultrasonic effects in the irrigating
solution than one that binds to canal walls (185).
US as an adjunct with various irrigating solutions contributes to the
removal of the smear layer (12, 145, 155, 176, 181, 186), however, it
seems to be less effective in enhancing the activity of EDTA (154, 163,
187–189).
Thirty seconds to 1 minute of ultrasonic activation seems to be
sufficient to produce clean canals (157), whereas others recommend 2
minutes (142). Shorter passive irrigation time makes it easier to main-
tain the file in the center of the canal, thus preventing it from touching
the canal walls (157). Syringe delivery of NaOCl every minute was as
effective as a continuous flow of NaOCl during 3 minutes of passive
ultrasonic irrigation in the removal of dentin debris (135).
For ultrasonic irrigation, the use of medium power was suggested
(171, 190 –192). It is of interest to note that a combination of low-
power US with NaOCl was not more effective than NaOCl alone (193,
194).
Ultrasonic vibration can also be effective when touching the shank
of a hand file inserted inside the canal. The hand file will transmit
vibrations to the irrigant inside the canal, but a greater risk for touching
dentinal walls exists.
To prevent a dampening effect, sonic or ultrasonic files should not
contact the canal walls; therefore, the use of smooth files is recom-
mended (157). In contrast, ultrasonically activated stainless steel files
tend to ledge and perforate canal walls because of their sharp cutting
surfaces (195) (Fig. 6). The use of a smooth wire during ultrasonic
irrigation in vitro was as effective as a K-file in debris removal (196).
Furthermore, US as an adjunct with EDTA enhanced the canal wall
cleanliness after post space preparation in endodontically treated teeth,
especially in the apical portion of the post space (197).
Ultrasonic Condensation of Gutta-Percha
Ultrasonically activated spreaders have been used to thermoplas-
ticize gutta-percha in a warm lateral condensation technique. In some
in vitro experiments, this was demonstrated to be superior to conven-
tional lateral condensation with respect to sealing properties and den-
sity of gutta-percha (198 –201). Ultrasonic spreaders that vibrate lin-
early and produce heat, thus thermoplasticizing the gutta-percha,
achieved a more homogeneous mass with a decrease in number and
size of voids and produced a more complete three-dimensional obtu-
ration of the root canal system (201). This technique has also been
evaluated clinically with favorable results (202).
A number of obturation protocols have been described for ultra-
sonic condensation of gutta-percha: (a) ultrasonic softening of the mas-
ter cone followed by cold lateral condensation (198); (b) one or two
times of ultrasonic activation after completion of cold lateral conden-
JOE — Volume 33, Number 2, February 2007
Review Article
Figure 6. SEM image of the instrumentation grooves on the root canal walls
created by an ultrasonic file (⫻1,150).
sation (203); (c) ultrasonic activation after placement of each second
accessory cone (201); or (d) ultrasonic activation after placement of
each accessory cone (200, 204, 205).
Warm lateral condensation combines the advantage of having con-
trol over the length of the root fill, similar to cold lateral condensation,
with the superior ability of a thermoplasticized material to replicate the
three-dimensional shape of the root canal (201). From a practical point
of view, ultrasonic condensation of gutta-percha is quickly mastered
and has several advantages over other warm lateral condensation tech-
niques. It was observed that heat was generated only during ultrasonic
activation, and the plugger appeared to cool rapidly once activation
ceased (204). The size of the heat carrier (ultrasonic spreader) can be
chosen to match the diameter of the root canal, and the ultrasonic
spreader can be curved to match the curvature of the root canal. Fur-
thermore, gutta-percha does not stick to the ultrasonic file when the
ultrasonic unit is activated (198). Also, the low temperature produced
by the unit at its lowest power setting may result in less volumetric
changes of gutta-percha upon cooling (206).
The obturation technique recommended when using the ultra-
sonic techniques (204, 205) consists of initial placement of a gutta-
percha cone to the working length followed by cold lateral condensation
of two or three accessory cones using a finger spreader. The ultrasonic
spreader is then placed into the center of the gutta-percha mass 1 mm
short of the working length and activated at intermediate power to
prevent charring of root surfaces and fracture of the ultrasonic
spreader. After activation, the ultrasonic spreader is removed, and an
additional accessory cone is placed, followed by energizing with the
activated ultrasonic spreader. This process is repeated until the canal is
filled. During each subsequent step, the ultrasonic spreader should be
placed slightly more coronally.
The ultrasonic spreader must be in the mass of gutta-percha for
about 10 seconds to achieve thermoplasticization. Leaving it in the canal
for more than 10 seconds can produce a rise in temperature that is
damaging to the root surface (204, 205).
In addition, it has been demonstrated that placement of sealers
with an ultrasonically energized file promoted a better covering of canal
walls with better filled accessory canals (evaluated by radiography) than
placement of sealers with hand instruments (207, 208).
Placement of Mineral Trioxide Aggregate (MTA)
Witherspoon and Ham (209) described the use of US to aid in the
placement of MTA. The inherent irregularities and divergent nature of
Ultrasonics in Endodontics 87
Review Article
some open apices may predispose the material to marginal gaps at the
dentin interface. It was demonstrated that, with the adjunct of US, a
significantly better seal with MTA was achieved (210). Placement of
MTA with ultrasonic vibration and an endodontic condenser improved
the flow, settling, and compaction of MTA. Furthermore, the ultrasoni-
cally condensed MTA appeared denser radiographically, with fewer
voids (210). These results contradicted those of Aminoshariae et al.
(211), who concluded from an in vitro study that hand condensation
was superior.
The recommended placement method consists of selecting a con-
denser tip, then picking up and placing the MTA with the ultrasonic tip,
followed by activating the tip and slowly moving the MTA material down
using a 1- to 2-mm vertical packing motion. Direct ultrasonic energy
will vibrate and generate a wavelike motion, which facilitates moving
and adapting the cement to the canal walls (Fig. 5i–l). In a case of
repairing a defect apical to the canal curvature, Ruddle (41) recom-
mends incrementally placing MTA deep into a canal, then shepherding
it around the curvature with a flexible trimmed gutta-percha cone uti-
lized as a plugger. A precurved 15 or 20 stainless steel file is then
inserted into the material and placed to within 1 or 2 mm of the working
length. This is followed by indirect ultrasound, which involves placing
the working end of an ultrasonic instrument on the shaft of the file. This
vibratory energy encourages MTA to move and conform to the configu-
rations of the canal laterally as well as controlling its movement.
This technique was recommended initially for placing MTA in open
and diverging apices, but it can also be used to put the material in
root-end cavities, in perforations, and especially in perforations of the
floor of the pulp chamber (Fig. 5i–n).
Surgical Endodontics: Root-End Cavity Preparation and
Refinement and Placement of Root-End Obturation Material
Recent developments of new instruments and techniques have sig-
nificantly enhanced the treatment outcome in apicoectomy with retro-
filling (212). As the prognosis of endodontic surgery is highly depen-
dent on good obturation and sealing of the root canal, an optimal cavity
preparation is an essential prerequisite for an adequate root-end filling
after apicoectomy (20, 213, 214).
Figure 7. Diamond-coated stainless steel ultrasonic surgical retrotips.
88 Plotino et al.
Figure 8. Smooth stainless steel ultrasonic surgical retrotips.
Root-end cavities have traditionally been prepared by means of
small round or inverted cone burs in a microhandpiece. In the mid-
1980s, standardized instruments and aluminum oxide ceramic pins
were introduced for retrograde filling (215), but that system could not
be used in cases with limited working space or in teeth with large oval
canals. Since sonically or ultrasonically driven microsurgical retrotips
became commercially available in the early 1990s (216 –219), this new
technique of retrograde root canal instrumentation has been estab-
lished as an essential adjunct in periradicular surgery (217, 220, 221).
However, the cutting properties of the retrotips at that time were limited
and seemed to be dependent on loading, power setting, and orientation
of the tip to the long axis of the handpiece (222, 223). In some retrotips,
cooling of the working tip was insufficient, and dentin and bone were at
risk of being overheated (20).
The first root-end preparation using modified ultrasonic inserts
following an apicoectomy is attributed to Bertrand et al. (224). Others
followed, but it was not until 1987 that Flath and Hicks (225) further
reported on the use of ultrasonics and sonics for root-end cavity prep-
aration.
Conventional root-end cavity preparation using rotary burs in a
microhandpiece is faced with several problems (21, 226, 227), such as
a cavity preparation not being parallel to the canal, difficult access to the
root end, and risk of lingual perforation of the root. Furthermore, the
inability to prepare to a sufficient depth, thus compromising retention of
the root-end filling material, means that the root-end resection proce-
dure requires a longer cutting bevel, thus exposing more dentinal tu-
bules and isthmus tissue, of which the latter is difficult to remove. The
development of ultrasonic and sonic retrotips has revolutionized root-
end therapy, improving the surgical procedure with better access to the
root end, resulting in better canal preparation (226 –229). Ultrasonic
retrotips come in a variety of shapes and angles, thus improving some
steps during the surgical procedures (213, 230, 231) (Figs. 7 and 8).
At first glance, the most relevant clinical advantages are the en-
hanced access to root ends in a limited working space. This leads to a
smaller osteotomy for surgical access because of the advantage of using
various angulations and the small size of the retrotips (232). However,
a number of studies compared root-end preparations made with mi-
crosurgical tips to those made with burs. They demonstrated additional
advantages of this technique, such as deeper and more conservative
cavities that follow the original path of the root canal more closely
(221, 233–237). A better-centered root-end preparation also lessens
the risk of lateral perforation (236 –238). Furthermore, the geometry
of the retrotip design does not require a beveled root-end resection for
JOE — Volume 33, Number 2, February 2007

surgical access (232), thus decreasing the number of exposed dentinal
tubules (20, 239 –241) and minimizing apical leakage (242–245).
They also enable the removal of isthmus tissue present between two
canals within the same root (234, 236, 246 –248). It is considered a
timesaving technique (234) that seems to have a lower failure rate (20).
The cleaning effect and the cutting ability of ultrasonic retrotips
have been described as satisfactory by many authors (222, 223, 233, 237,
249, 250). Furthermore, US produced less smear layer in a retro-end cavity
compared to a slow-speed handpiece (214, 221, 233–235, 251).
The refinement of cavity margins that were obtained with the ul-
trasonic tips may positively affect the delivery of materials into the cav-
ities and enhance their seal (214, 249, 252–254), even if cavities pre-
pared with erbium:YAG lasers have been shown to produce significantly
lower microleakage than ultrasonic preparations (255).
In a study by Walmsley et al. (256) the breakage of ultrasonic
root-end preparation tips was investigated and attributed to the design
of the tip. Increased angulation of retrotips increases the transverse
oscillation and decreases the longitudinal oscillation, putting the great-
est strain at the bend of the instrument. The authors suggested reducing
the angulation and increasing the dimensions of the tip to resist break-
age. This may be true, but a straighter design will restrict access and a
thicker instrument prevents instrumentation of isthmuses. A controver-
sial issue with sonic or ultrasonic root-end preparation is the formation
of cracks or microfractures and its implications for healing success
(257, 258). Some studies indicated that this was a possible drawback
(23, 238, 253, 259 –263). Other studies, however, disputed these find-
ings and did not report a higher prevalence of microfractures (19, 237,
264 –272). Khabbaz et al. (237) found that cracks did not correlate
directly with the surface area of the root-end surfaces but rather with the
type of retrotip used. Preparation with smooth stainless steel ultrasonic
tips produced fewer intradentin cracks than diamond-coated stainless
steel ultrasonic tips and sonic diamond-coated tips.
The influence of root-end microfractures on the periradicular
healing process and apical leakage should be clarified (226). Apical
resorption after healing (273) may eliminate the surface defects and
contribute to the overall success of treatment. Also, such defects can be
removed by finishing resected and retrofilled root-end surfaces (274).
Several in vivo studies reported excellent success rates when the root-
end preparation was performed using ultrasonic retrotips (21, 212,
275-283), thus demonstrating that modern surgical endodontic treat-
ment using an operating microscope and ultrasonic tips significantly
improves the outcome compared to the traditional techniques (284).
It is recommended that the ultrasonic unit be set at medium power
(267) and the cavities be prepared to a depth of 2.5-3 mm (285). This
depth allows for a minimum thickness of material that can still provide
an effective apical seal (286). The cavity walls should be parallel and
follow the anatomic outline of the pulpal space (230, 287). It has also
been suggested that root-end cavities should be initiated with a dia-
mond-coated retrotip, using its better cutting ability to provide the main
cavity. This aids in the removal of root canal obturation materials and
should be followed by a smooth retrotip to smooth and clean cavity walls
(248).
A condenser tip ultrasonically activated can be utilized for place-
ment of retrograde filling materials, as the ultrasonic vibration is meant
to improve the flow, settling and compaction of these materials to root-
end dentinal walls. This should improve the delivery of materials into the
cavity thus enhancing their seal (210).
Ultrasonic tips can also be used to polish root end material and
apical surfaces. Utilizing specific ultrasonic tips for refinement of the
external radicular surface may be beneficial in the elimination of ex-
traradicular bacteria, which may be responsible for infection (288,
289).
JOE — Volume 33, Number 2, February 2007
Review Article
Root Canal Preparation
Ultrasonic devices were introduced for use in root canal prepara-
tion in 1957 by Richman (9). In 1980, Martin et al. (11, 12) demon-
strated the ability of ultrasonically activated K-type files to cut dentin. A
commercial ultrasonic unit, designed by Cunningham and Martin
(147), was introduced in 1982. Barnett et al. (290, 291) and Tronstad
et al. (292) were the first to report on its use in endodontics.
Several studies have shown that ultrasonically or sonically pre-
pared teeth have significantly cleaner canals than teeth prepared by
hand instruments (14, 147–149, 293–296). Numerous studies have
analyzed the different characteristics of ultrasonically activated files,
such as cutting efficiency (11, 12, 297–302), effect on bacteria (168,
303, 304), characteristics of root canal preparation (153, 305–313),
mechanical and technical features of files and handpieces (314 –318),
and clinical implications (319 –323).
The results of the above studies can be summarized as being con-
tradictory. They failed to demonstrate the superiority of US or sonics as
a primary instrumentation technique, as no improved debridement was
accomplished compared with hand instrumentation (22, 140, 152,
160, 176, 194, 291, 324 –342). The relative inefficiency of ultrasonic
debridement has been attributed to file constraint within the unflared
root canal space (343). A modification of the technique in which ultra-
sound is activated for a few minutes after hand preparation has instead
resulted in greater canal and isthmus cleanliness compared with hand
preparation alone (151, 177, 344 –346).
Despite the multitude of studies conducted on ultrasonic root ca-
nal preparation with ultrasonically activated files, the current consensus
is that this is not a viable clinical technique.
Conclusions
It can be concluded from this review of the literature that US offers
many applications and advantages in clinical endodontics. Improved
visualization combined with a more conservative approach when selec-
tively removing tooth structure, particularly in difficult situations in
which a specific angulation or tip design permits access to restricted
work areas, offers opportunities that are not possible with conventional
treatment. As a result, access refinement, location of calcified canals,
and removal of separated instruments or posts have generated more
predictable results. In addition, better action of irrigation solutions and
condensation of gutta-percha have benefited from the use of US. Root-
end cavity preparation followed by placement of materials in an area
that is more often than not constrained has especially improved the
quality of treatment and long-term success. Finally, integration of new
technologies such as US, leading to improved techniques and use of
materials, has changed the way endodontics is being practiced today.
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