A STANDARDIZED ENDODONTIC TECHNIQUE UTILIZING NEWLY

DESIGNED INSTRUMENTS AND FILLING MATERIALS

John I. Ingle, D.D.S., M.S.D./' Seattle, Wa.~h.

I N'l'ROD\ JC'l'ION

arc!'ptanre of root rmUll thrrapy hy thc profession and thc public has
T HE
been a very slow proces.'l. Thc laity has long held doubts about the advisa-
bility of retaining the pn1p1ess tooth-doubts hased in part upon fears of focal
in fretiOIl. The pl'ofpssion, )wing' g.·PIleI'ally more sophisticated, is no longer
hlin<lly 01)('is(1l1t to the thpol'.\' of focal infeetioll. Crrtain nH'mb('rs of the pro-
f('ssion, hO\H'Vel', still 1'('ta1n some douhts concPl'ning tIll' ultimate sur('ess to he
ohtaillrd h~' ('ndorlontic t1'patmrut. Thesr professional doubts are !lot founded
on faets, fol' today it lIlay be reported that well-ex('cuted root canal therapy
is as sueressfu1 as an:,; ot1\('1' kind of dental treatment.
Sueces8 in I'!ldo<lontics, as in the othcr disciplin('s of dentistry, dl'mmHls
ea1'<'ful attl'lItion to ease sple('tio!l. This must he followed hy meti('ulous man-
agl'llH'nt of t 11<' ('ndodontic triad of ('anal preparation, sterilization, and ohtura-
tion.' Not a II ('IHlodontieally tl'('ated ('ases are Rueee8sful; nor, for that matter,
should WI' exp!'('t t ht'lll to be. How('v!'!', the ('ndodontist dot's ('xpect ahont flr>
l)('r (,Pllt su('cess, and when the oC('llsionnl failure (le('urs he is dismayed hy the
result.
SU('('Pss in anr ('IHleavol' is (h'lwlld('nt UPOJI a wPll-plamH'd approach eoupll'd
with a ('an'fui ('x('('utioll of IH'o('('dm'p. In spite of prior planning, unfol'pgpen
variahles ",hie1l limy pV('lltnally ('olltrilnltp to t'ailul't' al'P sOJ1lptimrs introduced.
OJl(, lpal'lIs 1I0t so IIllleh I),\' gloating' over 8t1<'('('SS('8 as h,\' ju(lieiollsly anal,\'zing
his failures. In so doing, ow, nUl:" det(,l'mine whel't'in ht' made mistakPs in
jndgllwlIt or mistal{('s of ('xecution ",hi('h 1lltilllCltl'ly INI to failtll'P. Lo~.d('all,\·,
th('11. corl'('('tioll of all (,l'l'or ill judglll('nt and/or t('clmiqllc sllOuld increase
sU('('l'ss.

To d<'tprmiHl' the 1'at(' of sneeess and, r()nY(,l'sl'l~', the rate and cause of
failtll'<\ the l)('lllll'tll]l'nt of Elldodontics of the Flliwl'8ity of Washington, a
Presentl"\ before the CongTl'Sll Intl'rn:wional O,lon!ologicll Argentino Uruguayo, Buenos
Aires, No\"pnlbpl', 19£i9.
This study was finane"" in part b)' the Star Dl'nta] l'.ranuflLcturing 0'0., Philadelphia,
Pennsylvania, and by rpsPRr'ch funds frolll \Vashington State Publie La\v 171.
·PrOff'RSOr and Ex(>('utiYf" Offt('(lJ'. ])ppartnwnt of P{>'l'iodontics and Entlodontics, "Gniver-
sity of "'ashington ~<'llllol of llentistl'Y.
 JNGLB O.S.. O.M. & 0.1'.
J anu ary, )96)

decade ago, beo'an an analytical study oC all root canal th rapy case tr atec1 in
the endodontic clinic and, in addition, ol ca, e treated by member' of the teach-
ing staff. Out of this study has come '01110 vel'Y inter ,ting in formation which
will be reported in a future pap r. For the present, however, it may b stated
that ndodonti failure occur, 5.!l5 pel' 'cni oi: th tim. Analy i of the ndo-
]ontic .failUl' s ha led to )'efinements in case selection and terhniqu which have,
in turn, en, ur c1 greater succ ss.

].'Ig. 1.- lncompl et e obtul'ation of th root canal a ccounts tor 58 .6G p r cent of all
endodontic failur s. H. ot 1'f'8cction in this ca se could in no way ovcrcom th toxic irt'itants
arising from the partially flllcd canals.

ENDODON'l'I }?AILUlm

DocumentaUon of the cau, es of cndodontic failul' wa th(' mo 1 siO'nificant

]evelopmenl of the Wasllington study. 'a analysis l'CV ale 1 improper htul'a-
tion of the root canal , pac as th , leadiug cause oC Jailul', [t was found that
5 .65 pel' cent of JOi: endodontic failul'es werc l'C'lated to the pooI'ly filled 1'001.
'anal (FiO'. 1). Th next great sl l'C380n Io1' Iailnr(' was l' lnted to L' ot p dora-
tion. However, thr'e op l'ativ [TOrS a'colmied 1'01' only ~),6~ ]leL' ('(\n1. or ihc
unsuccessful 'a s (Fig. 2).
Thus, it would appeaL' that poor root anal obturation i hy far the 'reatest
caus of endodonti· f'aiIUl'c, with inc'ol'l'eet canal instrllm ntation the n xt most
important a peeL Actually, thollgh, thc problem i hI' ad l' than this slatemrllt
would indicat. 'I' tal ohtuJ'ation is dependent, in tum upon cal' '[nl '0 ['onal
nncll'adirulu[' 'avity prcpm'ation HS well as pro])('l' C'usc s('lrriioll uncI the correct
nse or filling materials.
Vol"",. II 'l'.~KnARI [ZED ENDO])ON'L'L 'rE II CT [QUl~ 5
.s ullIhcr I

The jll'ol'cssion i , l'tl'I'Il;dly g l'atl'i'lIl tothe Ilite I)]' , Fl'<lncis('o M, Puc'i, or

fontc'video, l ' l'ugllny, 1'01' Ilis monUllll'l1tal contr ibu tions in the field 01 enclo-
dOll tiN;' 2 Jt was Pn 'ci who first poiJlt('(l out the lICCCs.~i t y 1'01' 111('tic1110u' intra-
COl' n<ll pl'cpal'ation as a basi fOl'llltimnl succe," in intl'al'aclicuhll' pl'cparation
Hnd obturatiolt, PU('ci' L I'etim' oC devotion to his profcssion has llOt bcen full),
apPl'cciaL <1 in o1'th \ mel'ica 01', fOJ' 1hat matter, in Central Burope, Many of
us )' aliz how \' r, 1 hat n maHer what asp ct of the subject is b in o' clisCUI';.<;cd,
Pucci uSl1all~' aid it fir t and h tter.

I.'lg. 2.- Jmproper canal instrum entation lea ding to perforation accounts for 9.62 p el'
cent o f th endodonti c f a illl!' S. This m a y b e I' l a tec1 to a limited-a c ss cavity 01' total
l ac k of unlfo l'n11ty In the enill.l'g ing i n sll'lIm nts.

LNll1inrr h a"il~- on Pucci, r PI' violls ly have clis(,l1ssed some 01' our prob-
lems, il1(,luclillg lh impOl'tl1l1c ot (,OI'1'('C'I 'ml (10111i(' ea,\'ity prepal'Dt'ion 3 and
em);!lobturatioll .' · '

IN~'I'R. :\IF;~'l' x LFOR~!lTY

R el1t impro\' 111 nt. in op rative rnllodontics and CRnal . i(,l'ilizntion leave
as 1h major endouonti probl 111 todHY th totHlla k o\: unirormit~, and stand-
ardization or
endod uti instl'UIll('utR nnd filling materials." '1'h current short-
('omin O' oC jll trument and filling mat rial nnifol'lnit~- may 1 e xpres ed in a
nllill bel' 0 [ ways:
1. Th r i.' at presen ( llO uni fOl'111 11 llmh ring system -for both inflt1'u-
m(\nL. and mat rials. 'rh Ill·hi.irar;)' nomenclatur 0 r: "fine," "me-
limn , " I1ml " oar e " is sometime. use 1, and the numerical (J -2-3-
-+-5-6) sy 'tell al 0 applies.
~. 'I'h('['(' is n uniform 'ystem for determination of in trumeni ize,
1h(' pres ntly available sizes h iJ1O' cntirely arbitrary.
3. 'l'!H'r is littl uniformity in mallui'acturinO' ontrol , with the r suIt
that instnUnt'11l or til \ ' am llumh('I' will i1' qu ntly vary gr atly
in perimet r.
 6 INGLl~ O.S .. O.M. & O.P.
J anuary, 1961

4, Th('re is no unifol'mity to Lhe progression from on in tl'lun nt gize

to the next; nor is t here an~' fOl'muJa for determining' the il1crem ni
oj' progl'c 'sion.
:5. Tlwre is no unifol'm corl'clation of instl'uJl)(,llts lind filling mat l'ials
in t<'l111S o[ sizc anu Hhapc.
6, Thcre has hecn no S(,1'ious att('mpt to l'eplace the tim('-honorcu plastic
gutta-pel'eha with a mcc1('l'll plastic thai is beH('!' adaptcd to til
prohl('m a ncl mOl'e ('<lsi ly (,Ol1t rolled in manuf<lC't U1'e,
Tn shori, th(,1'e has been an almOHt toLal abs lIe(' of. 1'('sea1'ch and develop-
ment in tll is al'ea of endodontics.

OPERA '1'1 VE ENDODO, ''1' ICS

Ideally, 011(' should he a1>l(' to lll'('pal'e a ('a\'ity within the ]'oot canal and
Lhcl'ealt<'l' plac<' a filling in the cavity with no int('l'mc<liaLe trial-anu-e1'1'o1' pl'O-
(·eclUl' s, Seic1lcl'G has d('!';cl'ibed tl1<' idC'al intl'al'ac1icular cavity as h in g round
Ilnd tap<'l'('(l , with a minimum op<'llillg' at th fOl'am(,l1. 'Phis st.\'Ie ot cavily may
h pJ'('pal'cd l'apidly and cffi(·iently hy mcans of 1'<'an1l'1'S to enhll'ge th(' apica l

"
,f

Fig. 3.-Le/t: P"eparatlon wilh reamer'S of the "rounrl, tap r d apical cavi ty with a mini-
mal opening at th foramen." Th e cavit~· is t "minat d 0.5 mm. from tit . apex. Th ovoW
portion or the canol I~ finished with tiles. Ri!JlIt: The opicul <"",Ity I" oblura t~d compl t ly
by a plastic 0" silver point cemented t o place. CenlE'nt tills th apical triangle cut by th
point of th reamer. The remainder of th(' canal Is obtUl'ated by sprradi n g th Initial point
aside and adding multiple tine gulla-I> rella pOints. (Cou,·t('sy D,·. Lest r Eo Br ('s, . nivc r -
aity of California.)

3 or 4 m Ill. of til eanal (Fig. 3) and file. to finish th ovoid pOlti n of ihc
canal.' In the small canals of molars :md prcmohlJ's, ],('lHneI'S alon will u unlly
comple1e the entir(' operation (Fig. 4 ), Op('rallng in the Pl'C's(,l1ce of the
ell lating ag nt, ethylencdiaminetc1raac tic ;)<'id (EDT \ ), gr ally 'implifi s
th proccdm·c. As long as the 1'001, canal is comparatively larg and la r ge in-
sLnul1('nLs may he used, this method of canal pl'('pa l'ation if> \'('l'Y ('fflcicni and
vcry rapid.
Trouble with this ieC'llllique d('velop when the l'oot canal lurn n i nal'l'OW
and curv d and th cnlarging instrument fit the callal tightly. l1d r the e
Volume 14 TANDARDIZED ENDODONTIC TEe.! [NIQUE 7
Number I

cil'cum tanc ,when a variance :in instrument size is encountered thc :instruments
either hind in the canal and are broken or shelf formation or perforation of the
root dey clop ,
'1'11 'econd siege of trouble is encotmt red when one attempts to fit a silver
or glltta-})C'l'cha point to the l'otUld-tapered cavity which has been prepared,s
The l1l'eSentJy avaHable filling materials are usually of a larger size than the
clllal'ning instruments o[ th same numbCl', ons quently, by trial and eITOl',
the del1tlst ('hoos, a filling point Ot 'malleI' size whi('h, in tUl'll, 111a:\' not ad -
Cluatcl)" obturate tIl canal spa 'e when cemented to place. 1\fOl'eOYC1', the shap
ot the pl'erol'mecl filling materials di.ffel's g'!' atly from the shapc of the instl'u-
m nt5, B ('aus the fimng mat rials are 0 inefficient, it is not unusual for the
final l' sult to he som what less than adequate.

Fi !:. 4.-.\ sil\' r point. newly standardiz d to the size and taper of the reamcr last
UH () In IJI't'PR I'ation , will, wh n c men ted to plae , assure total obliteration oC the r Of canal
"pace, :o;'olicc how th si!\'er point has b n weakened by notch ing with a carborundum disk
pl'iol' In seaUng. Th cut is mad at a mark 1 mm. above th e orifice so that, if necessary.
the [Joint ma~ bl' later removed. The axc ss is broken away by "worrying" the butt end
back un,1 IOt'tll until it breaks at the notch. Instrumentation of th e small canals in molal'''
>Lnd pl'l'll1o lat '~ mar be accomplishl'tl entirel y with reamers, en sur'i ng a l'ound, tapered
prepl\l'Iltlon .

Tit's lutiol1 t the ] J'obl III Ii in the development of compl tely uniform
ndodonti in tl'ument and filling materials. Uniformity can he promoted only
hyan acceptable formu1ation for all involyed supplie

S'l'AND.\ RDIZIW I~STRU;\lEXT'

POl't1UHltely, one of th dental manufacturers became interested in the uni-

formity problem and a now complete system of formulated endodontic instru-
m nt and filling materials ha be 11 developed and tested lor uniformity by
micro omp8l'at 1',7
88 INGLE O.S .. 0},1. & 0.1'.
J J.lluary. 1961

The following standardization has been accomplished:

1. A formula for the diameter and taper in each size of instrument amI
filling materials has been agreed upon.
2. A formula for a graduated increment in size from one instrul1ll'llt to
the next has been developed.
3. A new instrument-numbering system based upon instrument 11illll1-
eter is now being used.
4. Gutta-percha, as a filling material, is being l'e-evaluatcd with a
strong possibility that it will be replaced by a IH'wer plastic.
As demonstrated by Table I, a new numbering system using numbet·s from
10 to 100 has been developed. The number of the instrUIlH'llt is not just an
arbitrary figure but is based upon the diameter of the instl'UO]('llts in tenths

SPECIFICATIONS nLES AND Rt:AMERS SfLVER AN!) PLAHTl<' l'()I:'ll'I'S

l\EAREST mAMETER* DIAMETERt

OLD NEW
I
D,
I I D,
))1 !II
:-Il'MHER NUMBERS (MM.) (MM.) (MM.) ! ~DL)
0 10 0.1 0.4
1 15 0.15 0.45
2 20 0.2 0.5
3 25 0.25 0.55 0.25 0.;3;3
4 30 0.3 0.6 0.3 0.6
35 0.35 0.65 0.35 0.0;,
5 40 0.4 0.7 0.4 0.7
45 0.45 0.75 0.4;'5 0.75
6 50 0.5 O.R 0.5 O..~
55 0.55 0.85 0.55 0)'t3
7 60 0.6 0.9 0.0 o.n
R 70 0.7 ].0 0.7 1.0
9 80 O.R 1.1 O.R 1.1
10 90 0.9 1.2 0.9 1.~
11 100 1.0 1..1 1.0 1..'1
Specifications for newly designed and standardized root canal instruments and filling-
materials. Note the new numbering system based upon the tip diameter of the Instruments
in tenths of millimeters. The progressive increment in size from one instrument to the next
is 0.05 mm. through No. 60, after which the instruments progressively gain 0.1 mm. through
No. 100. No. 120 and No. 140 instruments are also now available.
The standardized taper of all instruments is achieved by an increase of U.:1 nHH. from
D, to D •• a point 16 mm. up the shaft. Note the minus tolerances for the points. This
slight difference allows for the cementing medium and compressibility of dentine dUring
enlarging.
·Tolerances Dl + 0.00 mm. -0.00 mm. D. + 0.00 mm. -0.00 mm.
tTolerances :0, + 0.00 mm. -0.01 mm. D2 + 0.00 mm. -0.01 mm.
(From Ingle, J. I.; In Grossman, L. I. [editor]; Transactions of the Second International
Conference on Endodontics, Philadelphia, 1958, Uniyersity of Pennsylvania.)

of millimeters at the beginning of the tip of the blades, a point called D, (Fig.
5). A No. 10 instrument, for example, is 0.1 mm. at D" whereas a ~o. 1;) is
0.15 mm., a No. 25 is 0.25 mm., and a No. 100 is 1.0 mm.
The progressive increment in size from one instrument to the ncxt is 0.05
mm. As Table I shows, there is an inereasc of 0.05 mm. in size from the ~o. 10
instrument through the No. 60 instrument. Thereafter, the increase in size is
0.1 mm. from the No. 60 instrument through the No. 100 instrument. There
are now fifteen instrument sizes in both files and reamers.
\·o!uml· 14
::\lIlllhcr I
STANDARDIZED ENDODONTIC TECHNIQUE 89

The cutting bladt's Ol ('ach instrument extend up the shaft 16 mm. from
point ])1, and this larger diauH'tcr is called 1)2. The diameter of each instru-
ment at D~ is 0.3 mill. greater than the diameter at Dl (Table I). Because of
the stallllardize<1 length of blade and the standardized diameter increase from
1)1 to 1)2' a formula may be established for uniform taper:

1~'~ mm. = 0.01875 mm. per millimeter

Length between . l1un.
D2 and Dl
or an intl't'ast' in each instrument of 18.75 microns per mm. of length. In short,
('Ilch instrllllWnt, no mattcr what size, will have the same taper of shaft.

01 ~02
I
F <,-:,=[
! ~;__ ;ii0
I i

Ftt::;:;· ;;:~;-;;;I
I
01 r - - - - I & m m --~O2.
I

1<'ig·..-,.-:-;e\\'ly liesig-neel endodontic instruments and filling- materials. uniform throughout

in size, taper, and length. The diameter of the instrument in tenths of millimeters at D, ele-
terlllin,,~ the number of the instrument (10 to 100). Point ~ is standarditoed at 16 rom. from
D,. The incrt'as~ in siz!' from D, to Do is 0.3 mm. in every size. The taper of every instrument
is, tlH'r<'fore, stan<lar<lizeil.
(}<'rom Grossman, L. T. [editor): Transactions of the Second International Conference on
En<l()<l()ntic~, Philadelphia, B;;S. t:ni\'ersity of Pennsylvania.)

The standardization oj' these instruments and filling materials is an ac-

cOlllplishpd j'[l(·t. The supplies are now available from dental supply depots
throug'hout the world. The silYer points are identical to the cutting instru-
lIwnts in numhe\', tapcl', and incl'rmrnt. On the other hand, the over-all di-
al11('t('r of the siiwl' points has been mane about 9 microns (0.009 mm.) smaller
than tlint of the f'nlarging' instrnnH'nts. This difference in size compensates for
the thi('kllPss of tlip cementing' medium, dentine compressibility, and the com-
mon fnilul'l' on till' part of the oprrator to utilize the instrument to the utmost.
90 INGLE O. '. O.i\!. & O.P .
J .lIlUory. 196 1

DISCUSSION

What advantages will accrue to the proI sion and to the endodontic patient
from these newly standardized materials
First of all, one may surmise that endodontic cavity preparation will im-
prove materially. There hould be fewer broken instruments and root P l'lol'a-
tions, which account fol' about 10 p r Ct'nt of Ollr endodontic failure'. Further-
more, a vast improvement in obturation will develop, for accw'ately adapt d
filling material may 110W he ('em ntecl to pJa' in accurately prepared canal
cavities (Figs. 3 and 4). Obviou:ly, the new mat rial will not 'olv all the
endodonti problems. In th hands of the ('al'eful operator, how vel', th new
materials should ensure a b ller grad of servi(,e for the patient, with an a -
suran(' of gr ater success and the bonus of a 'l<l \'ing in opel'atiuO' tim (Fig. 6).

Fig. 6. -A stan<l ard iz d endod nti c technique requl!'cR cOlllpl,· tt· ol'!tltnizRti on In oppraUon.
The stainless instrument case contributes greatly to this organization. Here cac'h Instru-
m ent has its own space.
The case has a hinged cover Rnd may b steriliz u in a llry-h(>at OV n . In ~ trum e nls and
supplies remain st erll th er ein and are removed with operating pliers only !is n 'deu.

The newly standardized ndodontic iustrum nt and filling material will

prove to be a major ad van e in the pro.fess ion of d ntistry.

CONCLUSIONS

1. The major cau 'es 01 endodontic Iail ure are incompJ te btmation 0 L th
canal space and incol'l'ect canal in trumentatioll.
2. ~Iany endodontic failure' are l' lat d to the total la'k of unifol'mil)' or
standardization in endodontic in trumcnts and fillinO' materials.
3. Endodontic in truments and filling materials which have h n :tand-
ardiz d in diamct r, taper, and graduat d ize incr mont arc now availabl e.
Volume 14
NlIlIlher I
Wl'ANl)AIWlZBD BNDODON'l'lC 'l'BCHNIQUE 91

1. Ingl .. , .John 1.: Root Canal Obturation, J ..Am. Dent. A. 53: 47·55, 1956.
2. Pu('ei, Frall(\isco M., and Reig, Roberto: Conducto8 Radiculares. Montevideo, Uruguay,
] 946, Casa a Barreiro y Ramos S. A.
;;, Ingh·, .J ohn 1.: Endodontic Instruments and Instrumentation, D. Clin. North America,
Pl" 805·822, Noyember, H)57.
4. Ingle, .John L: Ohlitprating the r'lnring Apical Foramen, D. Digest 62: 410·413, 1956.
;,. J nglc, .Tohn 1.: 'l'he N('cd for Bn<lotlontic TnRtl'Umcnt Standardization, OltAL SURG., ORAl.
M~;I>. & ORA[, PATH. 8: 1:l11·121:1, 1955.
fl. Seidler. n.: Root Canal Fillings: An Evaluation llJul Method, .T. Am. D!'nt. A. 53: 507·
576, 1956.
7. Tngle, .lo1m I.: The Npptl for Uniformity of En(lodontic Instrulllents, Equipment and
Filling l\Iaterial~. In Gl'Ossman, L. 1. (editor): 'l'ransactions of tlle Second I utero
national Confercll('C' on ]~n<1odontics, Philadelphia, ] 95S, University of PennRyivaniu,
pp. ]23·143.