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JOURNAL OF ENDODONTICS
Copyright 9 1985 by The American Association of Endodontists
CLINICAL ARTICLES
Endosonics: Clinical Impressions
Ultrasonido en Endodoncia: Impresiones Clinicas
Daniel G. Stamos, DDS, Gregory C. Haasch, DDS, Bruce Chenail, DMD, and Harold Gerstein, DDS
During a 10-month clinical study at the Endodontic
Department of Marquette University, we had the
opportunity to use and evaluate the endosonic unit
(Cavi-Endo). The unit was used for many proce-
dures: preflaring, canal preparation, pathfinding,
and the removal of obstructions, silver cones, and
posts. Clinical radiographs are presented which
demonstrate the various uses of endosonics along
with a discussion of how the unit was used, types
of problems encountered, and solutions to these
problems. The general consensus among us is that
the endosonic unit is a very valuable endodontic tool
with a multiplicity of uses.
Durante un periodo de estudio clinico de 10 meses
en el Departamento de Endodoncia de la Universi-
dad de Marquette, los autores tuvieron la oportuni-
dad de usar y evaluar la unidad de ultrasonido para
Endodoncia (Cavi-Endo). La unidad fue usada para
muchos fines: darle forma de embudo al conducto,
preparaci6n biomecanica, para encontrar el acceso
al conducto y para la remoci6n de obstrucciones,
conos de plata y pernos. Se presentan radiografias
clinicas que demuestran los variados usos del ultra-
sonido junto con una explicaci6n de c6mo se us6 la
unidad, los tipos de problemas que se encontraron
y las soluciones de estos problemas. El consenso
general entre todos los autores es que la unidad de
ultrasonido para endodoncia es un instrumento muy
valioso con una multiplicidad de usos.
One of the major goals of endodontic therapy is com-
plete tissue debridement from the root canal system.
In order to assure adequate obturation, proper prepa-
ration and debridement of the canal walls are necessary
(1-4). Several studies have shown that the morphology
of the root canal system makes complete debridement
181
Printed in U.S.A.
MOL. 11, NO. 4, APRtL1985
by mechanical preparation difficult (5, 6). To date, no
one cleaning technique has been shown to completely
debride the root canal system (7-9).
The first reported use utilizing ultrasound as an ad-
junct to mechanical debridement was reported by Rich-
man (10) in 1957. Since then many investigations have
been done, primarily by Martin et al. (12), to study the
use of ultrasound as an intracanal cleaning technique
(11-18). Histological studies have shown that canal
debridement combining ultrasonic energy with sodium
hypochlorite is extremely efficient (15, 19).
During this clinical study, the endosonic unit was
used primarily for preflaring, canal preparation, path-
finding, and the removal of foreign obstructions, silver
cones, and stubborn posts. The following is our com-
bined opinions, with a brief description of each proce-
dure for which the endosonic unit was used. Also
discussed are the types of problems encountered from
using the endosonics and how to minimize these prob-
lems.
MATERIALS AND METHODS
The source of the ultrasonic energy was the Cavi-
Endo unit distributed by Dentsply Inc., York, PA. The
files used were those supplied by the L. D. Caulk Co.,
Miford, DE. The conventional files came in sizes 15, 20,
and 25 while the diamond-coated files came in sizes
25, 35, and 45 (Figs. 1 and 2). The irrigant used was
either a 2.6% solution of sodium hypochlorite or tap
water.
Preflaring and Canal Preparation
The results of many studies demonstrate the superior
cleaning and cutting abilities of an endosonic system of
canal preparation (12-15). In a recent study, Goodman
et al. (19) reported a histological comparison of the
efficacy of the serial preparation versus a combined
serial/ultrasonic preparation in the mesial root canals of
182 Starnos et al.
60 extracted human mandibular molars. The 1- and 3-
mm levels were evaluated for percentage of tissue
removal within each canal and isthmus using a com-
pensating polar planimeter. The teeth prepared with
the serialization/ultrasonic technique were found to be
significantly cleaner than those in the serialization only
group (19).
In using the endosonic unit in canal preparation, a
FIG 1. Close-up photograph of endosonic files.
FiG 3. Maxillary left canine. A, Preoperative radiograph. B, Radiograph of completed case.
Journal of Endodontics
working length was first determined, after which the
canal was instrumented to a size 15 using a hand file.
When the file was loose inside the canal, it was removed
and the #15 endosonic file inserted. The endosonic file
was placed within a couple of millimeters of the working
length and the unit was activated. The irrigation may
be introduced by either an intermittent or continuous
flow. A solution of 2.6% sodium hypochlorite was used
FIG 2. Close-up photograph of endosonic handpiece.
Vol. 11, No. 4, April 1985 Endosonics 183

since it was as effective under ultrasonic influence as a which allows the irrigant to swirl down around the entire
5.2% solution without (20). The file was used in such a length of the file (Fig. 5) assures delivery of the sodium
manner as to brush the walls in an upward motion. hypochlorite to very tight canals. With the physical
When the solution in the chamber became cloudy, more actions of the ultrasound dislodging any calcifications
irrigant was added while the debris was evacuated by and the sodium hypochlorite penetrating and dissolving
means of the suction tip. The #15 file was used for no collagen, the canal system becomes more amenable to
longer than 60 to 90 s in the canal and removed. The file penetration. In many cases where the opening of
#20 endosonic file was used next, again for approxi-
mately 60 s and short of the apex. The diamond-coated
files, sizes 25 and 35, were used next to flare the canal,
keeping the files short of any curves. The tips are
manufactured with safe ends to prevent gouging of the
walls. One of the advantages of flaring with the diamond
file is that the operator may control the direction of
cutting, keeping away from a predetermined area. Once
the coronal portion of the canal was flared, the #20
endosonic file was reintroduced to smooth the junctions
of the diamond file to prevent a telescopic preparation.
When the canal walls were smooth, the apical 1 to 2
mm was prepared quickly with the use of hand files.
Figure 3 is representative of the type of canal prepa-
ration that can be achieved using endosonics.
One of the problems that can be encountered using
endosonics is zipping of the canal. Figure 4 demon-
strates one of the first cases prepared using endoson-
ics. The reason for the zipping was 2-fold. First, the
endosonic file was left in the canal too long and, second,
too large a file size, a #25, was used to the full working
length. The #25 file and the #45 diamond file have
been found to be too stiff and too large and are reserved
for larger canal spaces.
The answer of whether or not the endosonic file may
be used around curves without zipping or ledging is
yes. By precurving the file and using the smaller file
sizes, curves may be prepared without zipping.
Finally, the strict concept of standardized canal prep-
arations has to be altered as the endosonic files are
capable of producing preparations larger than their size. FIG 4. Maxillary right central incisor. Note zipping that occurred in the
A means of keeping a certain amount of standardization apical one-third.
is to prepare the last 1 to 2 mm by hand filing.

Pathfinding
The endosonic unit in this study was found to be a
(eliable pathfinding tool. Senia et al. (21) have shown
the effectiveness of 5% sodium hypochlorite as a tissue
solvent. This dissolving action has been shown by
Trepagnier et al. (22) to begin almost immediately when
the sodium hypochlorite is placed in contact with pulpal
tissue. Cunningham and Balekjian (20) compared the
collagen-dissolving ability of 2.6% and 5.2% sodium
hypochlorite at room temperature (21~ and body
temperature (37~ They (20) found that the 2.6%
solution when warmed to 37~ was equally as effective
in dissolving collagen as the 5.2% solution of sodium FiG 5. Close-up photograph of the head of the endosonic handpiece
hypochlorite at either temperature. illustrating the unique delivery of irrigation down the entire length of
The endosonics unique delivery system of irrigation the file.
 184 Stamos et ah
FIG 6. Maxillary right lateral incisor. A, Preoperative radiograph with no canal visible radiographically. B, Postoperative radiograph after using the
endosonic unit for pathfinding.
the canal was impenetrable with a small hand file, it
became soft and sticky. By using an alteration of small
hand files and Gly-Oxide followed by the use of the
endosonics, the canal might be more easily negotiated.
Many times a small round-ended bur was needed be-
forehand in order to remove sclerotic dentin over the
canal orifice. Care must be taken not to force the
endosonic file apically, otherwise, ledging or the for-
mation of a new canal may result. Let the instrument
"find its own way." Figure 6 demonstrates a success-
fully treated case.
Removal of Foreign Obstructions
In the past, the only means of negotiating around
foreign obstructions such as packed amalgam or gold
filings was to sit down and tediously pick through the
obstruction using a hand file. Many times this led to
mechanical perforations. By using the same principle
as that of a cavitren scaler used to remove amalgam
overhangs, so too can the endosonic unit be used to
remove amalgam or gold filings from the root canal.
The endosonic file, sizes 15 or 20, was introduced
into the canal to the point where the filings were packed
Journal of Endodontics
and the unit was activated with intermittent release of
2.6% sodium hypochlorite. The file is held in the canal
with a gentle up and down tapping action without
touching the walls. Within seconds, the filings become
dislodged by the cavitational action of the ultrasound
and quickly removed by the aspiration tip. A precaution
must be taken not to push the file in an apical direction
to try and "drill" through the filings. Otherwise the file
tip may be displaced to one side and a perforation could
result. Figure 7 illustrates a case in which endosonics
was used to remove packed filings.
Silver Point and Post Removal
The techniques for removing cemented silver cone(s)
and post(s) using the ultrasonic scaler have recently
been reported (23-25). The studies have all pointed out
the ease of removing cement from around the cone(s)
without being fearful of nicking the cone(s). The endo-
sonic unit works in much the same manner, with the
difference being that the file is part of the handpiece
and provides a continuous flow of irrigating solution.
The basic technique used was to explore the inter-
face between the silver cone or post and the canal
Vol. 11, No. 4, April 1985 Endosonics 185

the unit switched to the cavitron mode. The scaler, as

has been previously suggested, was placed on the post
until the seal was broken and the post freed (23).
Figure 8 illustrates the retreatment of two maxillary
premolars containing cast posts and cores and ce-
mented as one unit. Reduction of the core was accom-
plished with a carbide bur until the cement interface
could be seen. The composition of the post was of a
very soft metal. A post remover was used in an attempt
to retrieve the post but without success and resulted
in fracture of the post 2 to 3 mm below the canal orifice.
The endosonic unit was then used to remove the post.
Figure 9 shows the retreatment of a failed case filled
with a silver cone 15 yr earlier. The endosonic file was
used to loosen the silver cone and to shape and prepare
the canal. One of the unique properties of the endosonic
system is that it has been shown to significantly reduce
the amount of debris extruded apically (16). In a case
such as this, where there are corrosion by-products
which could be forced apically, it is important to remove
as much of the debris as possible to minimize any
postoperative discomfort to the patient (17). The com-
bination of high volume, continuous irrigation, and con-
stant aspiration coupled with the small instrument sizes
used resulted in less extrusion of debris.

FIG 7. Mandibular right first molar. A, Preoperative radiograph with

large distal amalgam. B, Radiograph showing approximately 3 mm of
packed amalgam filings. C, Radiograph immediately after using the
endosonic unit.

walls. Once a size 15 hand file was able to be intro-

duced apically a few millimeters, the endosonic file (size
15) was inserted alongside the cone and the unit was
activated. Sometimes a 700 R tapered fissure bur that
had been altered by removing the cutting edges on the
side of the bur was used to remove some of the cement
and at times to create room for the file (26). Once the
file was activated, the cement around the cone(s) was
loosened and the cone backs itself out of the canal or
it may be removed by grasping it. In cases with stub- FIG 8. Maxillary right first and second premolars. A, Preoperative
born posts, the endosonic handpiece may be removed radiograph showing cemented posts and calcified canals. B, Radi-
and replaced by an ultrasonic scaler and the setting on ograph after both cases were completed.
186 Stamos et al. Joumal of Endodontics

FIG 9. Maxillary right canine. A, Preoperative radiograph of a failed case obturated with a silver cone approximately 15 yr earlier. B, Close-up
photograph showing placement of the endosonic file alongside the silver cone. C, Radiograph of completed c~se.

SUMMARY
The many uses of the endosonic unit have been
presented. The techniques and problems that have
been associated with it have been discussed. An ad-
vantage which has not been discussed is that the use
of the endosonic instrument produces less operator
fatigue. Although riot every case can be successfully
treated, many otherwise inaccessible cones and dowels
have been removed and many calcified canals negoti-
ated. We believe that the endosonic unit has a place in
the practice of endedontics.
We are grateful to Dentsply International Inc. for providing the Cavi-Endo
units and to the L. D. Caulk Co., DMsion of Dentsply International for the
supply of endosonic files. Our appreciation is also extended to Howard Martin
for his slides of the Cavi-Endo unit and to Kathryn D. Scheets for her assistance
in preparation of this article.
Dr. Stamos and Dr. Haasch are currently second-year endodontic graduate
students at Marquette University Scho~ of Dentistry. Dr. Chenail is a recent
graduate and is currently teaching at the University of Saskatchewan School
of Dentistry and is in paR-time private practice. Dr. Gerstein is p~ofessor and
chairman, Department of Endodontics, Marquette University School of Den-
tistry, Milwaukee, WI.
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