Basic Research—Technology

In Vitro Evaluation of the Effectiveness of ProTaper

Universal Rotary Retreatment System for Gutta-Percha
Removal with or without a Solvent
Cristiane Midori Takahashi, MSc, Rodrigo Sanches Cunha, PhD, Alexandre Sigrist De
Martin, PhD, Carlos Eduardo Fontana, MSc, Cláudia Fernandes M. Silveira, MSc,
and Carlos Eduardo da Silveira Bueno, PhD

Abstract
Introduction: Effective removal of gutta-percha in
endodontic retreatment is a significant factor to ensure
a favorable outcome from failed procedures. The
E ven though advances in instruments and techniques have facilitated endodontic
therapy, clinicians must still deal with cases of failure caused by several factors
and requiring endodontic retreatment (1–3).
purpose of this study was to evaluate the efficacy of When nonsurgical retreatment is indicated, efficient removal of the filling mate-
a nickel-titanium rotary instrument system with or rial from the root canal system is essential to ensure a favorable outcome (4).
without a solvent versus stainless steel hand files for However, some studies have shown that it is almost impossible to remove the
gutta-percha removal. Methods: Forty extracted human root canal filling completely (5–7). Many techniques and materials have been
maxillary anterior teeth were prepared and filled. They used to obturate the root canal system, but gutta-percha combined with a sealer
were divided into 4 groups: Gates-Glidden and K-files, is still the most commonly used combination of materials. Several techniques can
Gates-Glidden and K-files with chloroform, ProTaper be used to remove the gutta-percha, including the use of stainless steel hand files,
Universal rotary retreatment system, and ProTaper nickel-titanium (NiTi) rotary instruments, heat-bearing instruments, and ultrasonics
Universal rotary retreatment system with chloroform. (8). In addition, use of a solvent is recommended to facilitate the removal of gutta-
The operating time was recorded. The teeth were longi- percha by softening it (9). Chloroform is the most commonly used solvent because
tudinally sectioned and photographed. The images were of its effectiveness. There are some limitations to its use, particularly because it has
analyzed and the filling remnants were quantified by been suggested that chloroform might be a potential carcinogen. Nonetheless, chlo-
using the IMAGE TOOL software. Results: With Krus- roform is considered safe if used carefully and in a clinically controlled manner
kall-Wallis test, statistical analysis showed that there (10). Another limitation is that chloroform leaves a fine layer or film of softened
was no significant difference between the techniques gutta-percha (11).
in regard to the amount of the endodontic filling Recently, a NiTi rotary instrument system was developed for gutta-percha removal,
remnants (P < .05); however, the ProTaper Universal the ProTaper Universal (Dentsply Maillefer, Ballaigues, Switzerland) system for retreat-
rotary retreatment system was faster than the hand files ment. It consists of 3 instruments: D1 with tip 30 and taper 0.09, D2 with tip 25 and
(P < .05). Conclusions: All of the techniques proved taper 0.08, and D3 with tip 20 and taper 0.07. In addition, the D1 working tip facilitates
helpful for the removal of endodontic filling material, initial penetration into the filling material.
and they were similar in material remaining after re- Nevertheless, there is no agreement about which methods should be used for the
treatment, but the ProTaper Universal rotary retreat- removal of root canal filling. Novel techniques seek improved results through NiTi
ment system without chloroform was faster. (J Endod rotary instruments and the operating microscope.
2009;35:1580–1583) The purpose of this study was to evaluate the efficacy of a NiTi rotary instrument
system (ProTaper Universal rotary retreatment system), with or without solvent, versus
Key Words stainless steel hand files for endodontic filling removal from root canals. The required
Gutta-percha, nickel-titanium files, root canal retreat- retreatment time for each system was also determined and compared.
ment, solvents
Materials and Methods
Specimen Preparation
From the Department of Endodontics, Centre for Dental Forty extracted single-rooted maxillary anterior teeth were selected with a single
Research São Leopoldo Mandic, Campinas, Sao Paulo, Brazil. straight root canal, fully formed apices in which the first file fitted at the apex was a size
Address requests for reprints to Dr Cristiane M. Takahashi, 15, and no calcification or internal resorption.
Centre for Dental Research São Leopoldo Mandic, Endodontics,
Av Abolião, 1810, Campinas, São Paulo, Brazil. E-mail address:
The crowns were removed with a diamond disk (KG Sorensen, Barueri, SP, Brazil)
cris_mtakahashi@yahoo.com.br. to leave a 16-mm root measured with the aid of calipers. A size 10 K-file was introduced
0099-2399/$0 - see front matter into the canal until it was visible at the apical foramen. The working length was deter-
Copyright ª 2009 American Association of Endodontists. mined by subtracting 1 mm from this measurement.
doi:10.1016/j.joen.2009.07.015
Root Canal Treatment
Instrumentation was performed by a single operator. The cervical third was
flared with sizes 3 and 2 Gates-Glidden drills (Dentsply Maillefer) in decreasing

1580 Takahashi et al. JOE — Volume 35, Number 11, November 2009
 Basic Research—Technology
order. Root canals were prepared by using a crown-down technique Evaluation
up to a size 35 K-type file (Dentsply Maillefer) apically and were The teeth were grooved buccolingually with a diamond disk and
flared cervically up to a size 50 K-type file. At each change of instru- sectioned longitudinally with a rongeur. Both root halves were photo-
ment, the canals were irrigated with 20 mL of a 2.5% NaOCl solution graphed with a camera (Sony PC120; Sony Corporation, Tokyo, Japan)
(Fórmula & Ação Famácia, São Paulo, SP, Brazil) per sample. When adapted to an operating microscope with 5 magnification. To evaluate
instrumentation of the root canals was completed, 17% ethylenedia- the remaining filling material, the images taken were transferred to
minetetraacetic acid was applied for 3 minutes for smear layer a specific software (Image Tool for Windows v.3.00; University of Texas
removal, and the canals were again irrigated with 5 mL of 2.5% Health Science Center, San Antonio, TX), which was used to measure the
NaOCl. areas of remaining filling material (Fig. 1) and root canal periphery that
The root canals were dried with paper points and obturated with were computed and expressed by using square pixels. The images of the
gutta-percha (Dentsply, Petrópolis, RJ, Brazil) and zinc oxide–eugenol sections were evaluated by 3 independent precalibrated examiners who
sealer (Endofill; Dentsply) by using thermomechanical compaction observed and quantified root canal filling remnants. Mean percentage
with a hybrid technique (12). This consists of a lateral compaction of values were calculated and compared.
cold gutta-percha followed by the application of a rotating gutta
condenser to thermally soften and condense the gutta-percha. The Statistical Analysis
coronal access cavities were sealed with a temporary filling material
The mean percentage amounts of remaining gutta-percha and
(Cavit; DeTrey Dentsply, Konstanz, Germany). All teeth were stored at
sealer for each group and the mean retreatment times were compared
100% humidity and 37  C for a period of 30 days to allow the sealer
by using the Kruskall-Wallis test (P < .05).
to set completely.
Results
Retreatment Techniques All of the teeth examined had some endodontic filling remnants in
The teeth were randomly divided into 4 groups with 10 specimens the canals. The mean amounts of remaining gutta-percha/sealer in each
each, and the temporary filling was removed. Gutta-percha was group are shown in Table 1. There was no statistically significant differ-
removed by using one of the following techniques. ence (P < .05) between the groups.
A significant statistical difference (P < .05) was found between the
Stainless Steel Hand Files (SS) Group. The gutta-percha was
groups in regard to retreatment time (Table 2). PTR group was faster
removed from the coronal and middle thirds with sizes 3 and 2 Gates-
than SS, SS + C, and PTR + C groups.
Glidden drills. A size 40 K-type file was then introduced into the root
canal by using a crown-down technique until the working length was
reached with a size 20 K-type file. Discussion
Stainless Steel Hand Files With Chloroform (SS+C) The complete removal of endodontic filling material is difficult (5,
7, 13–15), and it is one of the main goals of nonsurgical endodontic
Group. Gates-Glidden drills sizes 3 and 2 were used to remove the
retreatment. The root canal system of inadequately instrumented and
coronal and middle thirds of the filling material. A 0.1 mL of chloroform
obturated teeth is especially subject to presenting necrotic tissues
was placed in the canal to soften the gutta-percha. A size 40 K-type file
and microorganisms responsible for endodontic treatment failure
was then used to penetrate the softened gutta-percha by using a crown-
(16–18).
down technique until the working length was reached with a size 20 K-
A hybrid obturation technique was chosen in the present study
type file.
because it produces a better gutta-percha adaptation to the root canal
ProTaper Universal Retreatment Instruments (PTR) walls than the lateral condensation technique (6, 12, 19).
Group. ProTaper Universal retreatment instruments were used to re- Countless retreatment techniques have been suggested to effec-
move the filling material. D1, D2, and D3 were used sequentially, tively clean the root canal system, including stainless steel hand files
applying a crown-down technique, until the working length was
reached. The instruments were used with an electric motor (X-Smart;
Dentsply Maillefer) at a constant speed of 500 rpm for D1 and 400
rpm for D2 and D3, with a torque of 3 Ncm.
ProTaper Universal Retreatment Instruments with Chlo-
roform (PTR+C) Group. The technique used here was similar to
that used in PTR group, but 0.1 mL of chloroform was placed into
the root canal after using instrument D1. Next, the softened gutta-percha
was removed by using D2 and D3 sequentially until the working length
was reached.
On withdrawal, the files were cleansed of any obturating material
before being reintroduced in the root canal. Each file was discarded
after being used in 5 teeth. Irrigation with 2.5% NaOCl was performed
during the procedure at each change of instrument. All the teeth were
re-treated by a single operator.
Retreatment was considered complete for all groups when no
filling material was observed on the instruments, and no filling
material could be detected inside the canal by the operating
microscope (DF Vasconcelos S.A., São Paulo, SP, Brazil) with
12.5 magnification. The retreatment time was recorded for Figure 1. Measurement of area covered by filling material remnants in the
each tooth. IMAGE TOOL 3.00 software.

JOE — Volume 35, Number 11, November 2009 Effectiveness of ProTaper Universal Rotary Retreatment System for Gutta-Percha Removal 1581
Basic Research—Technology
TABLE 1. Percentage of Remaining Obturating Material in Root Canal System Under the experimental conditions of the present study, all tech-
after Retreatment niques proved helpful for removal of endodontic filling material, and
Group SS SS+C PTR PTR+C there were no significant differences between them. However, the Pro-
Taper Universal retreatment system without chloroform proved to be
Mean 15.4% 19.4% 21.1% 21.0% faster than the other experimental groups. Further studies are necessary
Maximum 20.2% 24.7% 28.0% 27.9%
Minimum 10.7% 14.2% 14.3% 14.2% to evaluate the effectiveness of this system in curved canals.
PTR, ProTaper Universal Retreatment Instruments; PTR+C, ProTaper Universal Retreatment
Instruments with Chloroform; SS, Stainless Steel Hand Files; SS+C, Stainless Steel Hand Files with References
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