ORIGINAL ARTICLE „ 101

Marwa M Bedier, Nehal N Roshdy

Efficiency of passive ultrasonic irrigation in removal

of root canal filling material using R-Endo and
D-RaCe retreatment systems
Marwa M Bedier,
Key words D-RaCe, passive ultrasonic irrigation, R-Endo, retreatment, stereomicroscope BDS, MSc, PhD
Lecturer, Endodontic Depart-
ment, Faculty of Dentistry,
Objectives: The aim of the present study was to evaluate the efficacy of R-Endo and D-RaCe Cairo University, Egypt

Retreatment instruments with and without using passive ultrasonic irrigation on the removal of root Nehal N Roshdy, BDS,
canal filling material, and the time required for its removal. MSc, PhD
Lecturer, Endodontic Depart-
Materials and methods: Sixty mandibular premolars with single canals were decoronated; the root ment, Faculty of Dentistry,
Cairo University, Egypt
canals prepared using the Revo-S rotary system and obturated with gutta-percha size (25/.06),
using lateral compaction technique. Roots were divided into four equal groups (n = 15) according Correspondence to:
Marwa Mahmoud Bedier
to the retreatment rotary system and the final irrigation technique used in the removal of root canal Email:
filling material into: R-Endo retreatment system with conventional irrigation (R-Endo/C), R-Endo m.bedier81@gmail.com
Tel: (+2)01006611104
retreatment system with passive ultrasonic irrigation (R-Endo/PUI), D-RaCe retreatment system with
conventional irrigation (D-RaCe/C) and D-RaCe retreatment system with passive ultrasonic irriga-
tion (D-RaCe/PUI). Roots were split into two halves longitudinally and the canal walls photographed
using a digital camera connected to a stereomicroscope. The remaining filling material in each root
canal third was evaluated using Image-J software. Data were analysed using the Mann-Whitney U
test for the rotary system comparisons and irrigation techniques, while Friedman’s test was used to
compare between the different root canal levels.
Results: There was a statistically significant difference in the total area percentage of the remaining
filling material among the four groups (P < 0.05). The D-RaCe/PUI group showed the least amount
of the remaining root canal filling material, followed by R-Endo/PUI, then D-RaCe/C, while the
R-Endo/C showed the highest amount.
Conclusion: D-RaCe/PUI group was the fastest and the most efficient technique in the removal of
the root canal filling material.
Conflict of interest: The authors declare that they have no conflict of interest.

„ Introduction complexity, improper root canal preparation, inad-

The goal of root canal treatment is to remove the
inflamed pulp remnants, prevent the occurrence of
periradicular disease and to promote the healing of
an already existing pathosis1. It has been recorded
that the success rate of proper root canal treat-
ment was more than 90%2,3, yet failure of certain
cases may occur due to the presence of anatomical
equate root canal filling or persistence of bacteria in
the dentinal tubules3-5. The non-surgical root canal
retreatment has been established as the treatment
of choice in a variety of situations and has widely
replaced endodontic surgery. It was indicated to
remove root canal filling materials, which adhere
to the canal walls and may harbour necrotic tissues
and microorganisms, and regain access to the apical

ENDO (Lond Engl) 2018;12(2):101–108

102 „ Bedier and Roshdy Efficiency of ultrasonic irrigation
foramen. This allows adequate instrumentation, dis-
infection of the root canal system and eliminates the
microbial infection6,7. Different methods and tech-
niques have been used for gutta-percha removal8,9;
studies have demonstrated that using nickel-titanium
(NiTi) rotary instruments accompanied by solvent
was more effective and less time-consuming10,11.
However, it was reported that the use of hand files
with or without solvent was considered a difficult
and time-consuming process, especially in cases of a
well-compacted gutta-percha12.
Recently, manufactures have provided the pro-
fession with special retreatment NiTi rotary files in
an attempt to improve the process of removing
root canal filling material. Among these files is the
R-Endo retreatment system (Micro-Mega, Besançon,
France), which possesses a triangular cross-section,
three equally spaced cutting edges, no radial land
and an inactive tip13, and the D-RaCe retreatment
systems (FKG Dentaire, La-Chaux-de-Fonds, Swit-
zerland) with its triangular cross-section and alter-
nating cutting edges14.
On the other hand, literature has also docu-
mented the use of passive ultrasonic irrigation (PUI)
in the disinfection of the root canals, removal of
root canal dressing, dentinal debris, organic tissue,
and calcium hydroxide from inaccessible areas15,16.
Studies have also evaluated the use of PUI for
the removal of root canal sealer and reported its
superiority over other techniques17. However,
few studies have evaluated the efficacy of PUI
in removing the remaining filling material during
endodontic retreatment. Thus, the purpose of the
present study was to assess the efficacy of R-Endo
and D-RaCe retreatment systems combined with a
conventional and passive ultrasonic irrigation for
the removal of root canal filling material, as well
as the time required for its complete removal in
extracted human mandibular premolars. The null
hypothesis was that there would be no statistically
significant difference between the different retreat-
ment instruments and irrigation techniques when
comparing the total area percentage of the remain-
ing filling material.
ENDO (Lond Engl) 2018;12(2):101–108
„ Materials and methods
„ Sample size calculation
Based on data from previous studies18,19, sample size
calculation was performed using IBM SPSS Sample-
Power Release 3.0.1, to identify the sample size for
each group. Using alpha (α) level of 0.05 (5%) and
Beta (β) level of 0.20 (20%) i.e. power = 80%. The
minimum estimated sample size was 15 specimens
per group for a total of 60 specimens.
„ Selection and preparation of teeth
Eighty-eight single-rooted human mandibular pre-
molar teeth, recently extracted due to prosthodon-
tics or periodontal disease, were collected from the
clinic of Oral and Maxillofacial surgery department,
Faculty of Dentistry, at Cairo University. Initial radio-
graphs were performed to ensure that all the samples
had mature apices with no calcification, root frac-
ture, cracks or internal resorption.
„ Root canal preparation
All the teeth were then decoronated at the cemento-
enamel junction with a diamond disc under water
coolant, to obtain standardised 16 mm-long root
segments. The canal patency was checked by placing
a size 15 K-file (Mani, Tochigi, Japan) into the canals
until it was visible at the apical foramen. Canals that
did not allow the placement of a size 15 file to the
apex and those wider than a size 20 file at the apex
were excluded. Sixty teeth with a single canal, round
cross-section and canal curvature between 0 and
10 degrees according to Schneider’s method20 were
included in the study.
The working length (WL) for canal preparation
was established by subtracting 1 mm from the length
of the file just visible at the apical foramen. Each root
canal was then mechanically prepared with Revo-S
NiTi rotary files (Micro-Mega) SC1 (size 25, 0.06
taper), SC2 (size 25, 0.04 taper) and SU (size 25, 0.06
taper) in a crown-down manner, using the X-Smart
Plus micro-motor (Dentsply Maillefer, Ballaigues, Swit-
zerland), following the manufacturer’s instructions.
Irrigation was done using 2 ml of 2.6% NaOCl
(Clorox, Cairo, Egypt) between each file. When

instrumentation of the root canals was completed,
3 ml of 17% ethylenediaminetetraacetic acid
(Dharma Research, Miami, USA) was used for 1 min
for smear layer removal, followed by 2 ml of 2.6%
NaOCl, and then 10 ml of distilled water as a final
flush.
„ Root canal obturation
Next, canals were dried with paper points and obtu-
rated using size 25, 0.06 taper gutta-percha master
cones coated with AH Plus sealer (Dentsply DeTrey,
Konstanz, Germany) using a lateral compaction tech-
nique. Obturation was considered complete when
the spreader no longer penetrated beyond the cervi-
cal line. The roots were radiographed in buccolingual
and mesiodistal directions to confirm adequacy of the
filing, then the roots orifices were sealed with Cavit
(3M ESPE, St Paul, MN, USA). The specimens were
incubated for 4 weeks at 37°C with 100% humidity.
„ Removal of the root canal filling
material
Roots were randomly divided into four main groups
(n = 15) according to the rotary system and the irri-
gation technique used for removal of the root canal
filling material, as follows: Group R-Endo retreatment
system with conventional irrigation (R-Endo/C), the
root canal filling material was removed using the
R-Endo retreatment files as per the manufacturer’s
instructions; in a crown-down technique using the
X-Smart Plus micro-motor, with a preset torque level
of 1.2 Ncm and a constant speed of 300 rpm. The
Rm stainless steel manual file (17 mm, 25/0.04) was
used first to create a pathway, followed by the nickel-
titanium rotary instruments; Re was used as an orifice
opener for initial bulk removal of the filling material
(25/0.12), R1 (25/0.08) was used in the cervical third,
R2 (25/0.06) was used in the middle third and, finally,
R3 (25/0.04) was carried to the full WL.
The retreatment procedure was considered com-
plete when the working length was reached, no ma-
terial was observed between the flutes of the files,
and the irrigating solution appeared to be clear of
debris. All of the root canals were finally irrigated
with 3 ml of 17% EDTA for 1 min with 30-gauge
needle tips (NaviTip, Ultradent, South Jordan, UT,
Bedier and Roshdy Efficiency of ultrasonic irrigation „ 103
USA), 2 mm short from the WL, followed by distilled
water, then 5 ml of 2.6% NaOCl for 1 min and 10 ml
of distilled water as a final flush.
For group R-Endo retreatment system with pas-
sive ultrasonic irrigation (R-Endo/PUI), the root canal
filling material removal was performed in the same
way as group R-Endo/C, except for the use of an
IrriSafe ultrasonic tip (IRR 25/21, Acetone group,
Merigance Codex, France), attached to a Satelec P5
Newtron XS LED Scaler (Acetone group), for final
passive ultrasonic irrigation. The ultrasonic tip was
passively inserted into the root canals 2 mm short
of the working length. Firstly, 17% EDTA was acti-
vated for 1 min, then distilled water, followed by
three activations with 2.6% NaOCl; each activation
was performed for 20 s, for a total of 1 min and the
solution was replenished between the activations,
before distilled water was used as a final flush.
For group D-RaCe retreatment system with
conventional irrigation (D-RaCe/C), the root canal
filling was removed with D-RaCe retreatment files;
DR1(30/0.10 taper) at a speed of 1000 rpm and a
torque of 1.5 Ncm for the cervical third and begin-
ning of the middle third and DR2(25/ 0.04 taper)
at a speed of 600 rpm and a torque of 0.7 Ncm
to the full working length. The same final irriga-
tion protocol used in the (R-Endo/C) group was
used for this group, while for the group D-RaCe
retreatment system with passive ultrasonic irri-
gation (D-RaCe/PUI), root canal filling material
removal was done in the same way as group
D-RaCe/C, except for the use of the ultrasonic tip,
where the final irrigation procedure was performed
in a similar way to group R-Endo/PUI.
There were no procedural errors such as defor-
mation or separation of retreatment instruments
recorded during the retreatment procedure in all
groups. One operator performed all the procedures.
„ Assessment of the efficiency of the
filling material removal
a) Stereomicroscopic evaluation of root
canal cleanliness
Roots were grooved buccolingually using a diamond
disc to a depth just before it reached the canal space.
The roots were then longitudinally split using a chisel
ENDO (Lond Engl) 2018;12(2):101–108
104 „ Bedier and Roshdy Efficiency of ultrasonic irrigation
and a mallet. Each half was photographed using a
digital camera connected to the stereomicroscope
(Olympus, SZX9, Tokyo, Japan) with 15× magnifica-
tion. The areas with remaining filling materials (gutta-
percha/sealer) in each root canal third (coronal, mid-
dle and apical) were identified, outlined and measured
by one blinded observer, with no attempt to differ-
entiate between gutta-percha and sealer remnants.
All images were analysed using Image-J software
(Image-J v1.44, US National Institutes of Health,
Bethesda, MD, USA.), and the ratio of the area of
the remaining filling in pixels/the area of the canal
segment in pixels was analysed and expressed as the
percentage of the remaining filling material in each
canal segment.
b) Timing of filling removal
A stopwatch was used to record the time required for
root canal filling removal, starting from the moment
of entering the canal with the first instrument until
the complete gutta-percha removal and final irriga-
tion using 2.6% NaOCl. The time of changing the
instruments and using other irrigating solutions was
not included.
„ Statistical analysis
Data of the percentage area of the remaining filling
material were statistically analysed using the stat-
istical package for Social Science Version 20 (SPSS,
IBM Corporation, NY, USA); numerical data were
explored for normality by Kolmogorov-Smirnov and
Shapiro-Wilk tests. All data showed non-normal
(non-parametric) distribution. The Mann-Whitney
U test was used to compare between the two rotary
instruments as well as the two irrigation techniques,
Friedman’s test was used to compare between root
levels and Dunn’s test for pairwise comparisons. The
significance level was set at P ≤ 0.05.
„ Results
The area percentage of the remaining filling ma-
terial after using different retreatment instru-
ments and irrigation techniques was then analysed
(Tables 1 and 2). Results showed that there was a
ENDO (Lond Engl) 2018;12(2):101–108
statistically significant difference in the total area
percentage of the remaining filling material between
R-Endo/C and D-RaCe/C groups (P = 0.020), while
R-Endo/C showed a statistically significantly higher
mean area percentage of the remaining filling ma-
terial than D-RaCe/C at the coronal and middle lev-
els (P < 0.05). There was no statistically significant
difference at the apical level between both groups
(P > 0.05). Regarding the root canal level, the ap-
ical level showed the highest area percentage of the
remaining filling material, followed by the middle,
and then the coronal level.
On comparing the retreatment instruments using
the passive ultrasonic irrigation technique, results
showed statistically significant difference in the
total area percentage of the remaining filling ma-
terial between R-Endo/PUI and D-RaCe/PUI groups
(P = 0.018), where R-Endo/PUI group showed a
statistically significantly higher area percentage of
the remaining filling material than D-RaCe/PUI
group (P < 0.05). Regarding the root canal level, the
apical level showed the lowest area percentage of
the remaining filling material, followed by the middle
and coronal levels.
Moreover, results showed statistically signifi-
cant difference in the total area percentage of the
remaining filling material when comparing differ-
ent irrigation techniques (P < 0.05), where the total
area percentage of the remaining filling material
was higher in the R-Endo/C (19.97 ± 10.05%) than
with the R-Endo/PUI (10.29 ± 4.860%) and with
the D-RaCe/C (14.45 ± 7.35%) than the D-RaCe/
PUI (5.75 ± 3.37%).
The time required for root canal filling material
removal was analysed and results showed stat-
istically significant difference between the four
groups (P = 0.001); D-RaCe/PUI group showed the
least time needed for the retreatment procedure
(2.29 ± 0.41), followed by D-RaCe/C (2.47 ± 0.34),
R-Endo/PUI (4.38 ± 0.96) and then R-Endo/C
(4.70 ± 1.40).
„ Discussion
Retreatment of root canal treated teeth is com-
mon in complex root canal morphology, procedural
errors, root canal overfilling, inadequate preparation
 Bedier and Roshdy Efficiency of ultrasonic irrigation „ 105

Table 1 Means, standard deviations (SD) and results of Mann-Whitney U test and Friedman’s test for comparison between
the area percentage of the remaining filling materials in the four tested groups.

Irrigation Root canal level R-Endo D-RaCe P value

technique (between
Mean SD Mean SD systems)

Conventional Irri- Coronal 14.90AE 1.09 9.94BE 1.17 0.040*

gation
Middle 19.84AD 7.46 13.75BDF 1.61 0.022*
Apical 25.16CF 12.53 19.67CF 3.56 0.075
Total 19.97F 10.05 14.45 7.35 0.020*
P value (between root canal levels) 0.005* 0.020*
Passive ultrasonic Coronal 10.14C 7.58 5.98C 3.35 0.075
Irrigation
Middle 14.21C 9.92 9.11CG 5.60 0.051
Apical 6.52ADG 3.05 2.16 BDG 1.89 0.047*
Total 10.29G 4.86 5.75 3.37 0.018*
P value (between root canal levels) 0.001* 0.045* –

*Significant at P ≤ 0.05,(A,B) in the same row indicate significant differences between systems, (C,D,E)
in the same
column indicate significant differences between root canal levels and (F,G) in the same column indicate significant differ-
ences between irrigation techniques.

or coronal leakage. Thus, the need for non-surgical Table 2 P values of the area percentage of the remaining
filling materials between the two irrigation techniques used
retreatment is important to remove all the canal fill- with the two retreatment systems at different root canal
ing material, perform further instrumentation and levels.
disinfection in the root canal21.
Various instruments have been proposed for Root canal R-Endo D-RaCe
level
gutta-percha removal; however, rotary instruments
have been recommended for their high efficacy,
P value Coronal 0.118 0.042*
safety and ability to decrease both patient and oper-
(between
ator fatigue22. Moreover, irrigation is essential, not Middle 0.349 0.006*
Irrigation
only in primary root canal treatment procedures, but techniques) Apical 0.001* 0.001*

also in non-surgical retreatment cases, as it allows Total 0.001* 0.009*

more canal debridement beyond that achieved with

root canal instrumentation23.
Passive ultrasonic irrigation (PUI) allows the root
canal to be filled with an irrigating solution and the
instrument moved freely inside the canal causing
“acoustic streaming”, which creates circular fluid
movement around the instruments24. Several studies
have shown that PUI enhances the ability of sodium
hypochlorite to remove dentine debris, necrotic tis-
sue and bacteria25. However, few studies addressed
the efficacy of PUI in removing root canal filling ma-
terial during endodontic retreatment.
Usually, root canals have different morphology
and shapes in cross-section that render it difficult to
clean and greatly influence the changes that may
occur after root canal preparation and after retreat-
ment. In order to minimise these changes that may
influence the results, mandibular premolar teeth with
single-round-straight canals were selected and stand-
ardised to a 16 mm root segment length13,26-28.
In this study, 2.5% NaOCl was used for routine
irrigation during the cleaning and shaping steps as
it fulfils the majority of the required criteria of an
irrigation solution, such as broad antibacterial effect
and organic material dissolution ability. NaOCl was
used in a 2.5% concentration, as higher concentra-
tions (5.25%) are highly toxic and cause degrada-
tion of the dentine matrix components, which affects
the mechanical properties of the teeth29, yet both
concentrations showed similar biocompatibility and
antibacterial effect30.
Smear layer removal was performed by using 3 ml
of 17% EDTA, as NaOCl lacks the ability to dissolve
inorganic material, then 10 ml distilled water was
used immediately after EDTA to avoid the prolonged

ENDO (Lond Engl) 2018;12(2):101–108

106 „ Bedier and Roshdy Efficiency of ultrasonic irrigation
effect of the chelating agent on the microhardness
of root dentine and adhesion to epoxy resin-based
sealer29. A further 10 ml of distilled water was used
as a final flush as the application of NaOCl irrigat-
ing solution alone strongly compromises the bond
strength between dentine and resin sealer31.
Root canals were prepared using Revo-S NiTi
rotary files and then obturation was done using
size 25, 0.06 taper gutta-percha master cones
coated with AH Plus sealer in the lateral compaction
technique32,33. Samples were then stored after in
100% humidity for 4 weeks at 37°C after obturation
to allow the sealer to set completely24.
The efficacy of removal of root canal filling ma-
terial has been assessed by radiographs, clearing
methods, cone beam computed topography, scan-
ning electron microscope and stereomicroscope35,36.
Although the evaluation of the remaining material
by stereomicroscope is considered an invasive
method and may cause the remaining filling mater-
ials to spread, care was taken during longitudinal
splitting of the teeth, and evaluation was carried out
using the Image-J software, which provides more
precise and accurate measurement than the scoring
criteria37.
Results showed that the area percentage of the
remaining filling material was higher with R-Endo/C
than the D-RaCe/C at the coronal and middle levels;
this may be attributed to the use of R1 (25/0.08) in
the cervical third, R2 (25/0.06) in the middle third
in the R-Endo group, while the use of DR1 (30/0.10
taper) for the cervical third and the beginning of the
middle third in the D-RaCe system. The apical level
of the root canal showed the highest area percent-
age of the remaining filling material in both sys-
tems26,35,38, which may be related to the use of R3
or DR2 to the full working length, where both have
the same apical size and taper (25/0.04) in addition
to the anatomical variations which are known to be
more in the apical third of the root canal9.
The present results are in agreement with those
reported by Fenoul et al13, who declared that R-Endo
files left filling material inside the root canal, espe-
cially in the apical third of the canals previously
prepared with HERO Shaper (Micro-Mega) to
size 30, 0.04 taper at the WL. Also, Jayasenthil et
al38 reported that the manual technique resulted in
cleaner root canal walls than when compared to the
ENDO (Lond Engl) 2018;12(2):101–108
R-Endo system in the retreatment of canals previ-
ously prepared by ProTaper Universal NiTi rotary
instruments (Dentsply Maillefer) and enlarged to
F3 (30/0.09) at the working length. Keles et al34
showed that R-Endo files neither completely remove
the root canal filling remnants nor the smear layer
for canals prepared with Revo-S files until size AS 40
(40, 0.06 taper) and with final apical enlargement
with a size 45 K-file.
The use of D-RaCe/C for root canal filling removal
showed less total area percentage of the remaining
filling material through the whole canal than when
using R-Endo/C; this is in agreement with the find-
ings of Rödig et al14, who attributed the high effi-
cacy of D-RaCe files to the deep space available on
the back of the blade, which allows better exit and
removal of the dentinal debris than other rotary files.
On comparing the irrigation techniques, the ac-
tivation of the final irrigant using PUI enhanced the
efficiency of both retreatment systems in removal of
the remaining filling, where the ultrasonic tip vibra-
tion induces acoustic streaming, which promotes the
removal of the filling material from the root canal
walls. Furthermore, the frictional heat produced
causes softening and displacement of the gutta-
percha from the root canal17,39-41.
Results revealed that the apical level showed
the lowest area percentage of the remaining filling
material followed by the middle and coronal levels
when using PUI after the retreatment instruments.
This is consistent with Capar et al42, who reported
the efficiency of PUI in the removal of the Ca(OH)2
medicament from a standardised groove in the ap-
ical part of the root canal due to the intense, small,
circular fluid movement created around the instru-
ments being closer to the tip than to the coronal end
of the instrument, with a more apically directed flow
at the tip43.
The time required for root canal filling removal
was the longest when using R-Endo/C, followed
by R-Endo/PUI, D-RaCe/C and then D-RaCe/PUI
group. This is in agreement with Garge et al44 and
Rödig et al14, who found that the D-RaCe retreat-
ment system was the fastest among all the systems
evaluated. This may be credited to the alternating
cutting edges and the smooth instrument surface
that contributes to its superior sharpness. In addition
to the use of a DR1(30/0.10 taper) file at a speed of

1000 rpm for the cervical third and the beginning
of the middle third with its active tip, which allows
easy and rapid penetration into the gutta-percha
accompanied by the use of DR2(25/ 0.04 taper) file
at 600 rpm speed to the full working length. More-
over, Kasam and Ballagere27 reported the ability of
ultrasonic instruments to remove the filling material
from the root canals in a short period of time.
In conclusion, the D-RaCe retreatment system
seemed to be more efficient in the removal of the
root canal filling material than the R-Endo system.
Furthermore, the effectiveness of both systems was
enhanced when the final irrigant was activated using
ultrasonic instruments.
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