doi:10.1111/iej.

12610

CASE REPORT

Root canal treatment of a dilacerated

mandibular premolar using a novel
instrumentation approach. A case
report

A. Chaniotis1 & C. Filippatos2

1
Private Practice, Kalithea; and 2School of Dentistry, National and Kapodistrian University of
Athens, Goudi, Athens, Greece

Abstract

Chaniotis A, Filippatos C. Root canal treatment of a dilacerated mandibular premolar using a novel
instrumentation approach. A case report. International Endodontic Journal, 50, 202–211, 2017.

Aim To report on a novel method to instrument a dilacerated double-curved mandibular

premolar.
Summary A 45-year-old female was referred suffering from diffuse pain emanating
from the mandibular right quadrant. The second premolar (tooth 45) was diagnosed
with symptomatic irreversible pulpitis. The radiographic examination revealed a dilacer-
ated S-shaped root configuration, with 2 severe curvatures of <2 mm radius. Under
local anaesthesia and rubber dam isolation, a glide path was created until a size 10 K-
file reached working length. Instrumentation to larger size was achieved with a novel
approach using controlled memory files. The controlled memory files were pre-curved
and passively inserted below the curvature until maximum frictional resistance. The
motor was activated by maintaining light apical pressure, and the files were withdrawn
from the canal. This procedure was repeated until each file could reach the working
length. Chemical disinfection was achieved with positive syringe irrigation of 6%
NaOCl, followed by 17% EDTA rinsing and manual dynamic gutta-percha activation of
the irrigants. Canal filling was achieved using the continuous wave of condensation
technique and thermoplasticized injectable gutta-percha backfill. The postoperative
radiography revealed that the initial canal anatomy of the dilacerated double-curved root
canal was preserved.
Key learning points
• The passive insertion of controlled memory files into a dilacerated canal until they
met resistance and their withdrawal with activation may be useful for the enlarge-
ment of curved canals.
• The pre-bending of controlled memory files before activation may facilitate the nego-
tiation of dilacerated canals.

Correspondence: Antonis Chaniotis, 140 Eleftheriou Venizelou str, 17676, Kalithea, Greece
(Tel.: +302109562380; Fax: +302109562398; e-mails: antch8@me.com or antch@otenet.gr).

202 International Endodontic Journal, 50, 202–211, 2017 © 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd
Keywords: dilacerations, double curvature, instrumentation, novel approach, rotary

CASE REPORT
instruments.
Received 4 August 2015; accepted 13 January 2016

Introduction

Anatomical variations of the root canal system such as severe canal curvatures of dilac-
erated teeth may compromise the objectives of canal preparation leading to severe pro-
cedural errors, such as root canal transportation (Seago et al. 2015) or unexpected
instrument fracture (Al-Sudani et al. 2012). The undesirable results of canal transporta-
tion, such as ledge formation, canal blockages, zip and elbow formation and apical or
strip perforation, may compromise disinfection efficacy, jeopardize the apical seal and
reduce the fracture resistance of the affected tooth (Wu et al. 2000, Hulsmann et al.
2005, Sch€ afer & Dammascke 2009). Likewise, a fractured instrument inside an infected
root canal system is a hindrance to the accomplishment of root canal treatment objec-
tives and can compromise the treatment outcome (Cheung 2009).
Usually, the more severe and complicated the canal curvature, the greater the risk of
transportation and unexpected instrument fracture, especially when larger apical prepa-
rations are targeted (Sch€ afer & Dammascke 2009, Al-Sudani et al. 2012). That is why,
in severely curved canals, clinicians often tend to reduce the apical instrumentation size
of canal preparations (Roane et al. 1985). Reducing the apical preparation size in highly
curved or double-curved canals seems logical for two reasons: (i) smaller diameter
preparations involve less cutting of the canal walls, reduced file engagement and conse-
quently a reduced likelihood for the expression of undesirable cutting effects, and (ii)
small diameter files are more flexible and fatigue resistant and therefore less likely to
cause transportation during enlargement (Roane et al. 1985).
Although smaller apical preparations in highly curved canals are safer, they may result
in reduced disinfection because of the increased difficulty in ensuring that irrigation
solutions are delivered to an appropriate canal depth. In highly curved canals, the ability
of irrigant solutions to be delivered to the critical apical third depends directly on the
ability of the instruments to create adequate apical preparations and on the selection of
the appropriate delivery techniques (Boutsioukis et al. 2010).
Achieving adequate instrumentation widths for maximum disinfection efficacy is one of
the greatest challenges during curved canal management. Over the years, several
approaches have been suggested for the preparation of severely curved canals, most of
them depended on operator skill, the selection of instruments and the adopted enlarge-
ment techniques (Hulsmann et al. 2005). Regardless of the techniques followed and the
instruments used, it is clear that the more complicated the curvature of a given canal, the
more difficult the enlargement to a proper apical size becomes (Martin et al. 2003).
The problem of mechanical instrumentation of curved canals dramatically intensifies with
dilacerations. Dilaceration is the result of a developmental anomaly in which there is an abrupt
change in the axial inclination between the crown and the root of the tooth (Jafarzadeh &
Abbott 2007). The criteria for recognizing root dilaceration vary in the literature. According to
some authors (Hamasha et al. 2002), a tooth is considered to have a dilaceration towards the
mesial or distal direction if there is a 90-degree angle or greater along the axis of the tooth or
root with a small radius, whereas others (Chohayeb 1983) define dilaceration as a deviation of
20 degrees or more of the apical part of the root from the long axis of the tooth.
In dilacerated teeth, the accepted basic endodontic techniques and instrumentation
protocols are challenging even for the most skilled clinician. Although the body of

© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 50, 202–211, 2017 203
 literature on this topic is limited, some important considerations during the treatment of
CASE REPORT

such teeth have been reported. Tomographic recognition and diagnosis of the multipla-
nar direction of the dilacerations, modified access cavity designs, pre-flaring, pre-curva-
ture of stainless steel hand files, avoidance of NiTi rotary instrumentation, calcium
hydroxide dressings mixed with glycerine and thermoplasticized gutta-percha filling
techniques have been suggested as possible adjuncts to overcome the difficulties
posed by dilacerations (Jafarzadeh & Abbott 2007). Although these treatment considera-
tions can be extremely helpful, in many cases, the prognosis will not become evident
until the practitioner has undertaken initial root canal treatment to determine whether
the canal can be completely negotiated and then adequately disinfected and filled.
Thus, it becomes clear that there is a great need for more predictable and reproducible
techniques to deal with such cases.
The aim of this study was to report the clinical and radiographic outcome of the root
canal treatment of a dilacerated mandibular premolar using a novel instrumentation
technique.

Case report

A 45-year-old female was referred suffering from a diffuse pain in the mandibular right
quadrant. Percussion and palpation testing elicited normal responses. Cold testing eli-
cited sharp lingering pain only from the right mandibular second premolar (tooth 45) that
lasted more than 40 s after the removal of the cold stimulus. The radiographic examina-
tion revealed a deep carious lesion in the crown of tooth 45 extending to the pulp
chamber of a dilacerated S-shaped root canal with two severe and abrupt curvatures
(Fig. 1a). Moreover, on the radiograph, the periapical tissues appeared sound with intact
lamina dura and normal PDL width and contour. The pulpal diagnosis was consistent
with symptomatic irreversible pulpitis, and the periapical diagnosis was consistent with
no radiographic periapical disease.
After inferior alveolar nerve block anaesthesia with 1.8 mL of 4% articaine with
1 : 100.000 epinephrine (Ubistesin Forte/3M ESPE, Seefeld, Germany), multiple tooth
rubber dam isolation was achieved (Fig. 2a). The distal carious lesion was removed, and
isolation was secured with rubber dam liquid (Cerkamed Dental Products, Stalowa Wola,
Poland). After accessing the pulp chamber, the bleeding pulp tissue was rinsed with 6%
NaOCl (Canal Pro Plus, Coltene/Whaledent, Langenau, Germany). The first attempt to
negotiate the apical third of the dilacerated root with a size 06 K-file (Mani Inc., Utsuno-
miya, Tochigi, Japan) was hindered at the level of the first abrupt curvature. The distance
from the buccal cusp to this point was recorded and defined as the coronal zone. To
achieve patency to length through the dilacerated root canal, the 06 K-file was pre-curved
2 mm from its tip with an endo bender instrument (Axis/SybronEndo, Orange, CA, USA)
and guided through the coronal zone to the level of the first abrupt curvature (Figs 1b,
2b,c). By rotating the file slowly with slight apical pressure, the canal below the abrupt
curvature was negotiated and proper orientation was recorded. The dilacerated S-shaped
canal deviated first towards the mesiolingual direction and then displayed an apical abrupt
curvature in the distobuccal direction. The three-dimensional anatomy of the doubled
curved canal was replicated by the plastic deformation of the K-files. In order to advance
the hand files to length, a watch-winding/pull motion was employed. In this case, a man-
ual glide path was created to a size 10 K-file (Mani Inc.) (Fig. 1c). The working length
was estimated electronically using a CanalPro working length electronic measurement
device (CanalPro Apex Locator, Coltene/Whaledent, Cuyahoga Falls, OH, USA). The distal
wall was built up with composite resin, and rubber dam isolation was repositioned to fit
just tooth 45. This was performed late during the procedure to facilitate isolation.

204 International Endodontic Journal, 50, 202–211, 2017 © 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd
 CASE REPORT
(a) (b) (c)

(d) (e) (f)

Figure 1 (a) Preoperative radiograph showing an S-shaped dilacerated root canal, (b) negotiation
and determination of the coronal zone, (c) working length estimation radiograph, (d) evaluation
radiograph with the glide path file placed to working length, (e) master cone fitting radiograph,
(f) postoperative radiograph.

A controlled memory Hyflex EDM glide path file (size 10, .05 taper) (Coltene-Whale-
dent) was mounted on the hand piece of an endodontic motor (Canal Pro, Endo Motor,
Coltene/Whaledent), pre-curved 2 mm from the tip and passively inserted through the
coronal zone to the level of the first abrupt curvature without activation. The apical bend
of the file was guided towards the mesiolingual direction until a tactile sensation of
maximum engagement below the curvature was felt (Fig. 3a). Maintaining apical pres-
sure at the point of maximum engagement, the motor was activated (speed 500 rpm &
torque 3 Ncm) and withdrawn from the canal (Fig. 3b,c). The canal was irrigated and
patency was verified with a pre-bent size 10 K-file that was guided to full length. The
flutes of the glide path file were cleaned, and the file was reinserted inside the highly
curved canal the same way as before. Upon the second insertion, maximum engage-
ment was felt further apically inside the canal (Fig. 3d). By maintaining apical pressure
at the new point of maximum engagement, the motor was activated and withdrawn
from the canal (Fig. 3e,f). This method allowed the Hyflex EDM glide path file to be
safely guided through both severe curvatures until it reached the estimated working
length (Figs 3g,h, 1d, 2d). Once the desired length was reached a size 15, .04 taper, a
size 20, .04 taper and a size 25, .04 taper Hyflex CM files were used with the same
method. Patency was maintained throughout the whole procedure. With this novel
technique, maximum engagement is always felt for with a nonactivated file. This tech-
nique is best described by the term Tactile Controlled Activation (TCA) of engine-driven
files.

© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 50, 202–211, 2017 205
CASE REPORT
(a) (b) (c)

(d) (e) (f)

Figure 2 (a) Multiple tooth rubber dam isolation, (b) pre-curved 06 K-file negotiation, (c) the small
file is guided through the coronal zone to the level of the first abrupt curvature, (d) the Hyflex EDM
glide path file (size 10, .05 taper) placed to working length, (e) the sealer is pushed further apically
with the use of a canal brush, (f) view of pulp chamber after completion of root canal filling.

Chemical disinfection was achieved using positive syringe irrigation and 6% NaOCl
solution (Canal Pro-extra, Coltene/Whaledent,) delivered through a 30-Gauge needle, and
followed by 17% EDTA solution (Canal Pro, Coltene/Whaledent). The final rinse before
drying the canals was performed with 6% NaOCl. A corresponding size 25, .04 taper mas-
ter gutta-percha point, was fitted to length with the canal flooded with 6% NaOCl and
manual dynamic agitation of the irrigant was performed for 4 min (Fig. 1e). The canal was
dried with micro-capillary suction (Roeko surgitip endo, Coltene/Whaledent) and coated
with AH Plus sealer (Dentsply Maillefer, Ballaigues, Switzerland). The sealer was pushed
further apically by activating a canal brush (Roeko Canal brush) (Fig. 2e). The tip of a size
25, .04 taper gutta-percha cone, was coated with sealer and fitted slowly to full length.
The root canal was filled using continuous wave technique in combination with thermo-
plasticized injectable gutta-percha backfill. A size 30, .04 taper System B plugger, was
used to the level just below the abrupt curvature, and the tooth was backfilled with inject-
able gutta-percha (Fig. 2f). The tooth was restored with composite resin. The postopera-
tive radiograph of the dilacerated root canal can be seen in Fig. 1f.

Discussion

Knowledge of root canal anatomy is a prerequisite for preparing highly curved root
canals. It is well known that the root canal system of human teeth rarely exhibits
straight cylindrical canals. Instead, it usually has curvatures and aberrations. Sch€
afer

206 International Endodontic Journal, 50, 202–211, 2017 © 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd
 CASE REPORT
Figure 3 (a) Motionless insertion of a pre-curved engine driven NiTi endodontic file into the root
canal until a tactile sensation of maximum engagement is felt, (b) activation of the file at the point
of maximum engagement, (c) withdrawal of the file from the canal, (d) the second time, maximum
engagement is felt further apically, (e) activation of the endodontic file at the new point of maxi-
mum engagement, (f) withdrawal of the file from the root canal, (g) the glide path file is passively
guided to the working length without activation, (h) withdrawal of the glide path file.

et al. (2002) found that 84% of root canals were curved and that 17.5% of them had a
second curvature and were classified as S-shaped root canals. Amongst the S-shaped
canals, these that are dilacerated are considered quite rare and when encountered dur-
ing root canal treatment are challenging. S-shaped canals are considered dilacerated
when at least one of the curvatures has a 90-degree angle or greater with a small
radius (Hamasha et al. 2002). In the present case, 2 opposite directional curvatures of
90 degrees with 2 mm radii defined the dilaceration.
In such teeth, it is often extremely difficult to explore and negotiate the root canal
because of the abrupt apposition of the canal wall. Therefore, when an endodontic hand
file is introduced into the root canal early during the procedure, it might be blocked by
such irregularities. For initial scouting, it is essential to use stainless steel hand files that
can be pre-curved to negotiate and follow the abrupt curve and not just cut in a straight

© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 50, 202–211, 2017 207
 direction. The extent of the pre-curvature required for each instrument depends on the
CASE REPORT

abruptness and the location of the curvature along the canal length (Jafarzadeh &
Abbott 2007). Once the abrupt curvature of a dilacerated canal has been negotiated,
the stainless steel hand file requires some sort of rotation to be guided to working
length rather than a push and pull motion. In the present case, a watch-winding/pull
motion was used until a glide path of size 10, .02 taper could be created. Attempts to
achieve larger preparation sizes with stainless steel files resulted in extreme torsional
forces and were abandoned.
To achieve larger preparations, the use of NiTi hand or engine-driven instruments
must be considered. Superelastic (SE) NiTi alloys are softer than stainless steel, have a
lower modulus of elasticity (about one-fourth to one-fifth that of stainless steel), are
more resilient and show shape memory and superelasticity (Baumann 2004). SE NiTi
alloys can exist in two different stress and temperature-dependent crystal structures
(phases): martensite (low-temperature phase, with a B19’ structure) and austenite (high
temperature or parent phase, with B2 cubic crystal structure) (Santos et al. 2013).
Whenever stress is applied to austenitic NiTi alloys at body and room temperature, a
martensitic transformation of the austenitic crystal structure takes place (Santos et al.
2013). The resulting martensitic structure can accommodate greater stress without
increasing the strain making the files more flexible than stainless steel and suitable for
rotation or reciprocation. When the stress is being released, the SE NiTi alloy returns to
its austenitic superelastic crystal structure.
Although these files were shown to follow smooth curvatures better than stainless
steel (Tan & Messer 2002, Paque  et al. 2005, Ajuz et al. 2013), they are not suitable to
be guided through severe and abrupt curvatures. The restoring forces of these files
straighten them inside the canal and block further advancement below the curvature.
Although pre-curving of SE NiTi files is feasible, it results in plastic deformation and
work hardening of the metal making the files prone to fracture. Another option to con-
sider would be flaring of the coronal part of the canal. In some cases, flaring might facil-
itate the negotiation of SE NiTi files around an abrupt curvature by lengthening the
radius of the curvature. However, in abrupt curvatures, the smaller the radius of the
curvature, the more extensive the coronal flaring should be. Extreme flaring usually
results in increased dentine removal compromising the long-term function of the tooth.
Even if an SE NiTi instrument manages to negotiate around the curvature, a dilacerated
canal with greater and more acute curve subjects the instrument to even greater restor-
ing forces. In the case of a rotary SE NiTi instrument, the increased severity of the
angle and radius of the curves, around which the instrument rotates, decreases its lifes-
pan (Peters 2004).
Recently, a new thermo-mechanical processing of NiTi alloys resulted in the produc-
tion of a new wire with very unique properties called controlled memory (CM) wire.
Contrary to SE NiTi wire, files made with CM wire were found to be extremely flexible,
fatigue resistant and without the tendency to restore themselves to their original linear
shape (Peters et al. 2012, Bu €rklein et al. 2014). CM NiTi instruments were shown to be
mainly in the martensitic phase at body and room temperature, and they exert no
rebound effect upon removal of the load (Santos et al. 2013).
Such files without restoring forces were found to be able to rotate around abrupt cur-
vatures passively with minimal canal transportation towards the inner curves (Bu € rklein
et al. 2014). Moreover, the lack of restoring forces may allow the pre-bending of these
files to facilitate their negotiation around abrupt curvatures. Additionally, the martensitic
nature of the alloy may account for the increased fatigue resistance reported for these
files (Peters et al. 2012). All these aforementioned unique properties may render these
files suitable to be used with a novel instrumentation approach.

208 International Endodontic Journal, 50, 202–211, 2017 © 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd
 The novel instrumentation approach followed in the present case can be described

CASE REPORT
by the term Tactile Controlled Activation (TCA). The TCA instrumentation technique can
be defined as the outstroke activation of an engine-driven file only after it becomes fully
engaged inside a patent canal. It utilizes file activation only after maximum engagement
of the flutes is achieved. This technique aims to minimize file engagement during
curved canal management using file activation only when needed. Starting from the
point of maximum engagement around an abrupt curvature, a passively inserted
engine-driven file can be activated by maintaining apical pressure and moved outwards.
In this way, tactile feedback from the canal anatomy is maintained throughout the shap-
ing procedure and the files move from maximum engagement without activation to no
engagement upon activation.
How an engine-driven instrument feels during clinical use offers little information
about the collective stresses on a file. In contrast to the practitioner’s usual reliance on
the tactile sensations of torsion for hand files, stress on rotary or reciprocating files, as
the result of the force of cutting, can most accurately be determined by the ability of
the file to resist advancement around curvatures whilst in action. Torsional forces of
engine-driven files are directly related to the amount of file engagement (Setzer &
Bo € hme 2013). When the active part of the engine-driven file is under engagement, the
torque required to rotate or reciprocate the larger diameter of the file may cause exces-
sive stress on the part of the file with the smaller diameter usually at the fulcrum of
the curvature resulting in failure. The minimum torque required for the maximum diam-
eter portion of the file to function in the canal can be more than sufficient to break the
smaller diameter of its tip if it binds in the canal near the fulcrum of the curvature (McS-
padden 2007). Techniques to minimize file engagement may prevent instruments from
failing even in highly complicated anatomies such as dilacerations. The TCA technique
is suggested so as to minimize file engagement.
The first engine-driven NiTi file inserted passively into the canal should have a tip that
is at least equal to or smaller than the last manual glide path file with a taper one to
two times larger. By inserting passively, the first pre-curved file until maximum resis-
tance tactile feedback of the canal anatomy can be felt without experiencing the risk of
file fracture (Fig. 3a). The file is then activated by maintaining a constant apical pressure
at this point and withdrawn from the canal (Fig. 3b,c). The activation of a file in such a
way results in the enlargement of the canal at the fulcrum of the curvature to larger
sizes than the originally inserted instrument. The result is the releasing of the torsional
stresses at this exact point and the smoothening of the curvature. The next time that
the same file is passively inserted below the curvature inside the canal the tip of the
file is expected to reach further apically as the canal is now larger and the curvature is
reduced (Fig. 3d). By activating the file again in the same way, more dentine is safely
removed further apically with minimal file engagement (Fig. 3e,f). The same steps are
repeated until the point that the passively inserted file can reach the full working length
(Figs 1d, 3g). The completion of the work performed by this file marks the transition
from the manually achieved glide path to a glide path that larger engine-driven files can
follow (Fig. 3h). Larger sized files can be used with the same technique to minimize
engagement and to avoid transportation of the dilacerated canal.
It is mandatory to verify patency and irrigate between each TCA cycle to ensure the
unobstructed tactile sensation of file engagement. The tactile sensation achieved with a
passively introduced file can be affected by the initial canal shape, the canal length, the
canal taper, the canal curvature, the content and the irregularities of the canal as well
as the flexibility of the instruments used. Although TCA outstroke shaping is applicable
with all engine-driven NiTi files, instruments with controlled memory (CM) characteris-
tics were selected for the present case.

© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 50, 202–211, 2017 209
 Inserting a SE NiTi file passively inside the dilacerated canal would demonstrate a
CASE REPORT

false tactile sensation of frictional resistance early during the procedure guided by its
restoring force. Contrary to the SE NiTi files, controlled memory files can be inserted
passively inside such canals, generating a more accurate tactile sensation of file deflec-
tion and engagement. Activating a SE NiTi file that is under maximum engagement at
the fulcrum of the curvature might result in increased torsional forces making the file
extremely vulnerable. On the contrary, controlled memory files are passively engaged
around curvatures minimizing the expected torsional stresses upon activation. Activat-
ing a file that is passively engaged inside the canal might be safer than activating a file
that is engaged under the tension of its restoring force, especially when it comes to lar-
ger preparation sizes and dilacerated anatomies like the one reported herein.
The present case report provides a novel approach for the management of dilacer-
ated double-curved root canals. However, similar results may be achieved using alterna-
tive techniques with other file systems.

Conclusions

The management of dilacerated, severely curved or multicurved root canals requires

thorough knowledge of root canal morphology and selection of the most appropriate
instruments and techniques. In the present case report, a novel instrumentation tech-
nique was suggested for the mechanical preparation of a dilacerated premolar. This
novel method may be found to minimize engagement, reduce the risk of iatrogenic
errors, allow larger apical preparation of dilacerated canals and maintain the original
canal trajectory. Further research is needed to evaluate this novel technique for curved
canal management.

Acknowledgement

Dr. Antonis Chaniotis reports personal affiliation with Coltene/Whaledent outside of the
submitted work. The other author has stated explicitly that there is no conflict of inter-
est in connection with this article.

Disclaimer

Whilst this article has been subjected to Editorial review, the opinions expressed,
unless specifically indicated, are those of the author. The views expressed do not nec-
essarily represent best practice, or the views of the IEJ Editorial Board, or of its affili-
ated Specialist Societies.

References

Ajuz NC, Armada L, Goncßalves LS, Debelian G, Siqueira JF Jr (2013) Glide path preparation in
S-shaped canals with rotary pathfinding nickel-titanium instruments. Journal of Endodontics 39,
534–7.
Al-Sudani D, Grande NM, Plotino G et al. (2012) Cyclic fatigue of Nickel-Titanium rotary instruments
in a double (S-shaped) simulated curvature. Journal of Endodontics 38, 987–9.
Baumann MA (2004) Nickel-titanium: options and challenges. Dental Clinics of North America 48,
55–67.
Boutsioukis C, Gogos C, Verhaagen B, Versluis M, Kastrinakis E, Van der Sluis LW (2010) The
effect of root canal taper on irrigant flow in root canals evaluated using an unsteady Computa-
tional Fluid Dynamics model. International Endodontic Journal 43, 909–16.

210 International Endodontic Journal, 50, 202–211, 2017 © 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd
 €rklein S, Bo
Bu €rjes L, Sch€afer E (2014) Comparison of preparation of curved root canals with Hyflex

CASE REPORT
CM and Revo-S rotary nickel-titanium instruments. International Endodontic Journal 47, 470–6.
Cheung GSP (2009) Instrument fracture: mechanisms, removal of fragments, and clinical outcomes.
Endodontic Topics 16, 1–26.
Chohayeb AA (1983) Dilaceration of permanent upper lateral incisors: frequency, direction, and
endodontic treatment implications. Oral Surgery Oral Medicine and Oral Pathology 55, 519–20.
Hamasha AA, Al-Khateeb T, Darwazeh A (2002) Prevalence of dilaceration in Jordanian adults. Inter-
national Endodontic Journal 35, 910–2.
Hulsmann M, Peters O, Dummer P (2005) Mechanical preparation of root canals: shaping goals,
techniques and means. Endodontic Topics 10, 30–76.
Jafarzadeh H, Abbott PV (2007) Dilaceration: review of an Endodontic Challenge. Journal of
Endodontics 33, 1025–30.
Martin B, Zelada G, Varela P et al. (2003) Factors influencing the fracture of nickel titanium rotary
instruments. International Endodontic Journal 36, 262–6.
McSpadden J (2007) Mastering endodontic instrumentation. Chattanooga, TN: Cloudland Institute.
Paque F, Musch U, Hu €lsmann M (2005) Comparison of root canal preparation using RaCe and Pro-
Taper rotary Ni-Ti instruments. International Endodontic Journal 38, 8–16.
Peters OA (2004) Current challenges and concepts in the preparation of root canal systems: a
review. Journal of Endodontics 30, 559–67.
Peters OA, Gluskin AK, Weiss RA, Han JT (2012) An in vitro assessment of the physical properties
of novel Hyflex nickel-titanium instruments. International Endodontic Journal 45, 1027–34.
Roane JB, Sabala CL, Duncanson MG Jr (1985) The “balanced force” concept for instrumentation
of curved canals. Journal of Endodontics 11, 203–11.
Santos LA, Bahia MG, de Las Casas EB, Buono VT (2013) Comparison of the mechanical behavior
between controlled memory and superelastic nickel-titanium files via finite element analysis.
Journal of Endodοntics 39, 1444–7.
Sch€afer E, Dammascke T (2009) Development and sequelae of canal transportation. Endodontic
Topics 15, 75–90.
Sch€afer E, Diez C, Hoppe W, Tepel J (2002) Roentgenographic investigation of frequency and
degree of canal curvatures in human permanent teeth. Journal of Endodontics 28, 211–6.
Seago ST, Bergeron BE, Kirkpatrick TC et al. (2015) Effect of repeated simulated clinical use and
sterilization on the cutting efficiency and flexibility of Hyflex CM nickel-titanium rotary files. Jour-
nal of Endodontics 41, 725–8.
Setzer FC, Bo €hme CP (2013) Influence of combined cyclic fatigue and torsional stress on the frac-
ture point of nickel-titanium rotary instruments. Journal of Endodontics 39, 133–7.
Tan BT, Messer HH (2002) The quality of apical canal preparation using hand and rotary instruments
with specific criteria for enlargement based on initial apical file size. Journal of Endodontics 28,
658–64.
Wu MK, Fan B, Wesselink PR (2000) Leakage along apical root fillings in curved root canals. Part I:
effects of apical transportation on seal of root fillings. Journal of Endodontics 26, 210–6.

© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 50, 202–211, 2017 211