CLINICAL

Tactile controlled activation technique

with controlled memory files

Antonis Chaniotis1

The ultimate biologic objective of endodontic therapy is the prevention of periradicular

disease and the promotion of healing when disease is already established. Arguably,
mechanical instrumentation and chemical disinfection of the root canal system are
considered the foundational principles for the successful accomplishment of these
objectives (Schilder, 1974). Although these principles cannot be considered separately,
canal preparation is the essential phase that will determine the efficacy of all subsequent
procedures (Peters, 2004).
Traditionally for gutta percha fillings, root canal shaping should satisfy specific design
objectives:
• The shape of the main root canal should resemble a continuously tapering funnel
from the orifice to the apex
• The cross-sectional diameter of the main canals should be narrower at every
point apically
• Canal preparation should follow the shape of the original root canal
• The original position of the apical foramen should be preserved
• The apical opening should retain its original dimensions as much as possible (Schilder,
1
Dr Antonis Chaniotis graduated 1974; Hulsmann, Peters, Dummer, 2005).
from the School of Dentistry, The biological objectives of root canal instrumentation consist of: the confinement of
University of Athens, Greece, in instrumentation to the limits of the roots themselves; the avoidance of extruding necrotic
1998. In 2003, he completed debris into the periradicular tissues; the removal of all organic tissue from the main
the three-year postgraduate canals as well as from the lateral extent of the root canal system; and the creation of
programme in endodontics at sufficient space to allow irrigation and medication by simultaneously preserving enough
the School of Dentistry, circumferential dentine for the tooth to function (Hulsmann, Peters, Dummer, 2005).
University of Athens. He is a Achieving these objectives in straight canals is considered a simple and
clinical instructor affiliated with
straightforward procedure with all instrumentation systems available today. The problems
the undergraduate and
of biomechanical instrumentation arise when the internal anatomy of human teeth is
postgraduate programmes in the
endodontics department at the
severely curved or even bifurcated and anastomotic (Figure 1).
dental school, and owns a In such teeth, the accepted basic endodontic techniques and instrumentation protocols
private practice in Athens limited might be challenging to follow.
to microscopic endodontics since The aim of this article is to describe the application of tactile controlled activation
2003. He has been clinical (TCA) technique with controlled memory files for the safer and more predictable
fellow of dentistry at the instrumentation of severely curved and challenging canals.
University of Warwick since
2012. Dr Chaniotis has The challenge of curved canal management
published articles in local and The internal anatomy of human teeth can be extremely complicated. Based on canal
international journals and he has curvature, Nagy et al (1995) classified root canals into four categories: straight or I-form
lectured at more than 40 local
(28% of the root canals), apically curved or J-form (23% of the root canals), entirely curved
and international congresses. In
or C-form (33% of the root canals) and multicurved or S-form canals (16% of the root canals).
2010, he joined the Roots Forum
and became well known for his
Schafer et al (2002) found that 84% of the human root canals studied were curved and
clinical skills through his 17.5% of them presented a second curvature and were classified as S-shaped root canals.
microscope-enhanced From all curved canals studied, 75% had a curvature of less than 27o, 10% had a curvature
endodontic video case with an angle between 27o and 35o and 15% had severe curvature of more than 35o.
management series. Traditionally, root canal curvatures were assessed by using the Schneider angle of

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 CLINICAL

Figure 1: Complex root and root canal anatomical challenges in endodontics.

curvature concept (Schneider, 1971). According to Schneider into three categories: small radius (r″4mm), intermediate radius
(1971), root canals presenting an angle of 5o or less could (r>4 and r″8mm) and large radius (r>8mm). The smaller the
be classified as straight canals, root canals presenting an radius of a curvature is, the more abrupt it becomes.
angle between 10o and 20o as moderate curved canals, All these attempts to describe the parameters of root
and root canals presenting a curve greater than 25o as canal curvature had one common denominator, the
severely curved canals. preoperative risk assessment for transportation and
Many decades later, Pruett et al (1997) reported that two unexpected instrument separation.
curved root canals might have the same Weine angle of
curvature, but totally different abruptness of curvature. In order The risks of canal transportation and instrument
to define the abruptness of curvature they introduced the separation
concept of the radius of curvature. The radius of curvature is According to the glossary of endodontic terms (American
the radius of a circle passing through the curved part of the Association of Endodontists, 2012), transportation is defined
canal. The number of cycles before failure for rotary as the removal of the canal wall structure on the outside curve
endodontic instruments significantly decreased as the radius in the apical half of the canal due to the tendency of the files
of curvature decreased and the angle of curvature increased. to restore themselves to their original linear shape. For stainless
Further attempts to describe mathematically and steel hand files and conventional nickel titanium hand or
unambiguously root canal curvatures in two-dimensional engine-driven files, the restoring force of a given instrument is
radiographs introduced parameters such as the length of the directly related to its size and taper. The bigger the size or
curved part of the canal (Schäfer et al, 2002) and the location taper of a given file is, the bigger the restoring force becomes
of the curve as defined by curvature height and distance due to the increase of the metal mass of the instrument.
(Günday, Sazak, Garip, 2005). If root canals were constructed precisely on the dimensions
Estrela et al (2008) described a method to determine the of our instruments, then transportation wouldn’t be a problem
radius of root canal curvatures using CBCT images analysed and our instruments would be well constrained inside the root
by specific software. Radius of canal curvatures was classified canal trajectories. Unfortunately, instruments are not well

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CHANIOTIS

the selection of the appropriate delivery techniques

(Boutsioukis et al, 2010).
Achieving adequate apical preparations for disinfection
without over-flaring the coronal part of highly curved canals
is one of the greatest challenges in endodontic
instrumentation. This is very true especially under the current
concepts of dentine preservation in endodontics.
Moreover, the risk of unexpected instrument separation of
engine-driven nickel titanium files poses significant problems
during curved canal management. There are two
mechanisms that have been implicated with engine-driven
Figure 2: The effect of flaring in the curvature parameters.
instrument fracture, cyclic fatigue and torsional failure. As an
constrained by the canal in a precise trajectory, because engine-driven instrument is activated inside a curved canal,
instruments are not precisely shaped to fit the canal dimensions. continuous tensile and compressive stresses at the fulcrum of
As a result, each instrument may follow its own trajectory inside the curvature may lead to instrument separation because of
a curved canal guided by its restoring force and transporting cyclic fatigue. If the tip of an engine-driven instrument is
the canal (Plotino et al, 2010). Usually, the greater increase in locked inside a canal and the shaft of the instrument keeps
apical enlargement is targeted in curved canals, the more on moving, it may exceed an applied shear moment,
excessive the dentine removal towards the outer apical curve resulting in torsional failure. Usually during curved canal
becomes (Elayouti et al, 2011) and the more excessive the management both mechanisms can co-exist. As the
inner curvature (danger zone) widening can get. complexity of the curvature increases, the number of cycles
In order to avoid these complications, the more severe the before failure decreases for a given instrument, making
canal curvature is, the more we tend to increase flaring and complicated canal management a real clinical challenge.
reduce the apical instrumentation size (Roane, Clement,
Carnes, 1985). Increasing flaring under such circumstances Controlled memory files to minimise instrumentation risks
would result in the reduction of the angle of curvature, in Nickel titanium alloys are softer overall than stainless steel,
shortening the length of curvature, in increasing the radius of have a low modulus of elasticity (about one fourth to one fifth
curvature and in relocating the curvature apically (Figure 2). that of stainless steel), greater strength, are tougher and more
Smaller apical preparations in highly curved canals would be resilient and show shape memory and superelasticity
preferable for two reasons: (Baumann, 2004). The nickel titanium alloys used in root
• Smaller diameter preparations are related to less cutting of canal treatment contain approximately 56% (wt) nickel and
the canal walls, less file engagement and consequently, a 44% (wt) titanium (Walia, Brantley, Gernstein, 1988). They
lesser likelihood for the expression of undesirable cutting can exist in two different temperature-dependent crystal
effects structures (phases) called martensite (low-temperature phase,
• Small diameter files are more flexible and fatigue resistant with a monoclinic B19’ structure) and austenite (high
and therefore less likely to cause transportation during temperature or parent phase, with the B2 cubic crystal
enlargement (Roane, Clement, Carnes, 1985). structure). The lattice organisation can be transformed from
The aforementioned instrumentation approaches, although austenitic to martensitic and return again to austenitic phase
safer, have inherent disadvantages. Unfortunately, flaring the by adjusting temperature and stress. During this reverse
canal entrance in order to achieve easier negotiation to the transformation the alloy goes through an unstable intermediate
apical third of curved canals will result in unnecessary crystallographic phase called R-phase.
removal of dentine from a level that is considered Preparation of the root canal causes stress to nickel
irreplaceable. Moreover, smaller apical preparations may titanium files and a stress-induced martensitic transformation
result in increased difficulties for the irrigation solutions to be takes place from the austenitic phase of conventional nickel
delivered to an appropriate canal depth. In highly curved titanium files to the martensitic phase within the speed of
canals the ability of irrigation solutions to be delivered to the sound. A change in shape occurs, together with volume and
critical apical third depends directly on the ability of our density changes.
instruments to create adequate apical preparations and on This ability of resisting stress without permanent deformation

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– going back to the initial lattice form – is called zone showed that the martensite transformation in the shape
superelasticity. Superelasticity is most pronounced at the memory nickel titanium alloy caused 47% increase in the
beginning of the applied stress, when a first deformation of apparent fracture toughness (Wang, 2007).
as much as an 8% strain can be totally overcome. After 100 Very recently, controlled memory thermomechanical
deformations, the tolerance is about 6% and after 100,000 processing was combined with an innovative machining
deformations it is about 4%. Within this range, the so-called procedure for the manufacturing of rotary nickel titanium
‘memory effect’ can be observed (Baumann, 2004). endodontic files. The procedure is called electrical discharge
Besides the stress-induced martensitic transformation, the machining (EDM) and results in instruments of increased
lattice organisation of nickel titanium alloys can be altered surface hardness cutting efficiency and extreme fatigue
also with temperature change. When a conventional nickel resistance. In the first paper published evaluating these files
titanium austenitic microstructure is cooled, it begins to change (Pirani et al, 2015), spark-machined peculiar surface was
into martensite. The temperature at which this phenomenon mainly noticed and low degradation was observed after
begins is called the martensite start temperature (Ms). The multiple canal instrumentations. The authors also found high
temperature at which martensite is again completely reverted values of cyclic fatigue resistance and a safe in vitro use in
is called the martensite transformation finish temperature (Mf). severely curved canals. In agreement with these previews
When martensite is heated, it begins to change into austenite. researchers, Pedulla et al (2015) reported higher values of
The temperature at which this phenomenon begins is called fatigue resistance for EDM rotary files even when compared
the austenite transformation start temperature (As). The with reciprocating files made from M-wire.
temperature at which this phenomenon is complete is called The extreme flexibility and fatigue resistance of these files
the austenite finish temperature (Af), which means that at and combined with the lack of restoring force render them ideal to
above this temperature the material will have completed its be used for the instrumentation of highly curved and
shape memory transformation and will display its superelastic complicated canals. Whenever a conventional superelastic
characteristics (Shen et al, 2011). nickel titanium file is rotating inside a curved canal, it creates
Before 2011, the Af temperature for the majority of the its own trajectory guided by the restoring force of the file and
available nickel titanium endodontic instruments was at or transporting the canal toward the outer apical curve (ElAyouti
below room temperature. As a result, conventional nickel et al, 2011). The bigger the size or taper of the file used, the
titanium endodontic instruments were in the austenitic phase more dentine is removed from the outer apical curve, resulting
during clinical use (body temperature), showing shape in off-centred preparation at this level.
memory and superelasticity. In 2011, so-called controlled Leseberg and Montgomery (1991) studied canal
memory files were introduced in endodontics. These files had transportation at the level of the curve and documented the
been manufactured utilising a thermomechanical processing distal (toward the midline) movement of the original canal. They
that controls the material’s memory, making the files extremely
flexible and fatigue resistant but without the shape memory
and restoring force of other nickel titanium files
(Coltene/Whaledent, 2012).
The Af transformation temperature of controlled memory files
is found to be clearly above body temperature. As a result,
these files are mainly in the martensite phase in body
temperature (Shen et al, 2011). When the material is in its
martensite form, it is soft, ductile, without shape memory, can
easily be deformed yet it will recover its shape and superelastic
properties upon heating over the Af temperature. Moreover, a
hybrid martensite microstructure (like the Hyflex CM controlled
memory files) is more likely to have more favourable fatigue
resistance than an austenitic microstructure. At the same stress
intensity level, the fatigue crack propagation speed of austenitic Figure 3: Transportation dynamics of shape memory nicklel
structures is much faster than that of martensite ones. A titanium rotary files. Notice that the instrument removes material
quantitative analysis based on the model of the fracture process by touching the outer apical curve and the inner middle curve.

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were also demonstrated during the instrumentation of double

curved canals (Burroughs et al, 2012). In simulated S-shaped
canals, controlled memory files produced more overall
transportation compared to SAF and M-wire instruments.
Although the overall transportation was found bigger for no
shape memory files, they always transported the double
curved canal towards the outer curves. This is very important
in highly curved and double curved canals because the initial
dentinal thickness of human curved roots is always minimal at
the convexity of the inner distal curves (danger zones) or the
Figure 4. inner S-apical curves (Figure 5).

showed that canal transportation is caused by a combination TCA instrumentation technique

of forces resulting from the restoring force of the instrument that Root canal instrumentation involves the use of hand- or
rotates around the clinical and proximal view curvatures. These engine-driven files to create sufficient space for irrigation and
forces produce a transportation vector distally and axially at medication. The tactile feedback of the root canal anatomy
this level. From their study it would appear that for the middle felt by the operator during this procedure depends on various
third of a given curved canal, the greater the clinical and factors including: the initial canal shape (round, oval, long
proximal view curvatures the faster the transportation would oval or flat canals), the canal length (the longer the canal the
progress toward the distal concavity of the root. The dynamics more frictional resistance is expected), the canal taper
of apical and middle third transportation, as the result of the (tapering discrepancy between a gauging instrument and the
restoring force of the instrument and the degree of canal canal may cause false binding sensation), the canal curvature
curvature, can be seen in Figure 3. (curved canals can cause deflection of the instruments and
However, controlled memory files have no restoring force after increase frictional resistance), the canal content (fibrous or
bending in body and room temperature. Whenever an instrument calcified canal content can create different degrees of
with controlled memory characteristics is activated inside a frictional resistance), canal irregularities (attached pulp stones,
curved canal, it moves passively inside the anatomy producing denticles and reparative dentine can create convexities on
minimal forces of transportation. In highly curved canals, the lack root canal walls) and the type of instrument used (rigidity,
of restoring force keeps the CM files rotating towards the outer flexibility, tapering and restoring force can alter the frictional
canal wall at the fulcrum of the curvature (Figure 4). feedback) (Jou et al, 2004).
Similar transportation dynamics with controlled memory For a given root canal and a given file, the operator’s

Figure 5: Cases treated with Hyflex CM files. The arrows point to the areas of dentine preservation.

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Figure 6: Tactile controlled activation (TCA) technique explained.

tactile feedback during the instrumentation procedure differs orifices, technical patency to length is confirmed (Figure 6a).
according to the kinematics of the file used. Passively inserted The first file to be used is mounted on the handpiece of an
files (non-activated) give a tactile sensation that is determined endodontic motor and inserted passively inside the canal until
by the frictional resistance generated when the file engages maximum frictional resistance (Figure 6b – point B). The file is
the dentinal walls. The tactile sensation with an activated file activated and pushed apically (in-stroke) until the activated file
(rotating or reciprocating) however, as the result of cutting, resists further advancement (Figure 6c – point A) and
can more accurately be determined by the ability of the file withdrawn from the canal (Figure 6d). After file withdrawal,
to resist advancement around curvatures while in action the file is inactivated, the flutes are cleaned and checked for
(McSpadden, 2007). any possible deformations. Irrigation and patency confirmation
Keeping in mind the complexity of root canal systems and follows. The second time that the same file will be inserted
the need to minimise file engagement during instrumentation, passively inside the same canal it will reach deeper inside the
a novel approach was developed and named as the TCA anatomy (Figure 6e – point P). Activating the file again the
instrumentation technique. same way will guide the file even more apically closer to length
The TCA technique can be defined as the activation of a (Figure 6f – point A). The work to be done by this file is
motionless engine-driven file only after it becomes fully completed when the file can reach working length without
engaged inside a patent canal (Chaniotis, Filippatos, 2015). having to activate it and is then withdrawn (Figure 6g).
TCA utilises file activation only after maximum engagement of Instrumentation to larger apical preparations is achieved
the flutes is reached and a tactile feedback of the anatomy is the same way until the desired apical instrumentation width
felt. Inserting files passively (non-activated) inside the root is achieved. TCA technique aims to minimise the time of
canals and using controlled memory instruments that can be engagement with an activated file by using file activation
pre-curved before file insertion is suggested to be only when needed for advancement. With this
advantageous, especially when complicated canal systems instrumentation technique, most of the anatomical root canal
are encountered and limited mouth opening hinders canal variations can be enlarged safely to the desired
negotiation and visualisation. TCA technique can be divided instrumentation size, irrespective of the degree and
into in-stroke and out-stroke components. complexity of canal curvatures, by maintaining a tactile
After accessing the pulp chamber and locating the canal sensation of the anatomy throughout the whole procedure.

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Figure 7: Instrumentation of challenging cases to larger apical preparations with tactile controlled activation (TCA) and
controlled memory files.

For dilacerated canals, the controlled memory files can be instrumentation systems available today and they pose no
pre-curved in order to negotiate passively below the fulcrum significant problems to the clinician. The enhanced physical
of the abrupt curvature, activated at the point of maximum properties of controlled memory files manufactured with the
engagement and withdrawn from the canal (out-stroke) electrical discharge machining procedure makes it possible
instead of advancing them deeper. to shape a canal with the use of a single file in 360o
The next time that the same file will be inserted passively continuous movement. Most of these cases can be shaped
inside the dilacerated canal engagement of the flutes will quite quickly, effectively and safely by using a single Hyflex
be felt more apically. The file is activated the same way EDM file 25 (Coltene) with the TCA technique.
and withdrawn from the canal. This way, engine-driven files The one EDM Hyflex file has a tip size of 25 with a 0.08
can negotiate the apical third of dilacerated canals safely taper. The taper is a constant 0.08 in the apical 4mm of the
by maintaining a tactile sensation of the anatomy instruments but reduces progressively up to 0.04 in the coronal
throughout the whole instrumentation procedure (Chaniotis, portion of the instrument. The file has three different
Filippatos, 2015). cross-sectional areas over the entire length of the working part
Challenging cases of extreme canal curvature that were (rectangular in the apical part and two different trapezoidal
managed with TCA instrumentation technique with controlled cross sections in the middle and coronal part of the instrument)
memory files can be seen in Figure 7. to increase its fracture resistance and cutting efficiency (Pedulla
et al, 2015). Whenever larger apical preparations are
Controlled memory file sequencing required, three finishing Hyflex EDM files of constant taper can
The file sequencing during endodontic instrumentation is be used (40/04, 50/03 and 60/02).
directly related to the anatomical challenge encountered. In Constricted and obliterated canals, thin and long roots,
a roentgenographic investigation of frequency and degree of curved canals of more than 27o and S-shaped canals with
canal curvatures in human permanent teeth, 84% of the root smaller than 5mm radius of curvature are considered
canals were found curved and 17.5% of them presented a challenging for all instrumentation systems available
second curvature and were classified as S-shaped root canals nowadays. With controlled memory files, these cases are
(Schäfer et al, 2002). From all the curved canals, 75% were more effectively, safely and predictably enlarged with the soft,
found to have a small curvature of less than 27 degrees, 15% ductile and fatigue resistant Hyflex CM files by following a
a medium curvature ranging from 27 to 35 degrees and 10% simple standardised protocol and TCA technique.
a severe curvature of more than 35 degrees. After flaring with the 25/08 Hyflex CM flaring file and
Usually, patent root canals with a curvature of less than 27o glide path creation to 10/02 hand file, Hyflex CM files can
are considered easy and straightforward cases for most be used with the TCA technique in a standardised simple

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 CHANIOTIS

protocol of 15/04-20/04-25/04-30/04 and 35/04. Elayouti A, Dima E, Judenhofer MS, Löst C, Pichler BJ (2011) Increased
apical enlargement contributes to excessive dentin removal in curved root
This sequence is easy to remember and can work effectively
canals: a stepwise microcomputed tomography study. Journal of
and safely even in the most challenging situations of root Endodontics 37: 1580-4
canal instrumentation. Estrela C, Bueno MR, Sousa-Neto MD, Pécora JD (2008) Method for
determination of root curvature radius using cone-beam computed
The final enlargement will be dictated by the initial tomography images. Brazilian Dental Journal 19: 114-8
anatomy of each root. For glide path creation, the EDM Jou Y-T, Karabucak B, Levin J, Liu Donald (2004) Endodontic
10/05 glide path file can also be used after flaring and instrumentation width: current concepts and techniques. Dental Clinics of
North America 48: 323-335
initial canal scouting. In multi-canal teeth, easier canals can Leseberg DA, Montgomery S (1991) The effects of Canal Master, Flex-
be instrumented with a single EDM file 25, and the R, and K-Flex instrumentation on root canal configuration. Journal of
complicated ones with the aforementioned CM file Endodontics 17: 59
Günday M, Sazak H, Garip Y (2005) A comparative study of three
sequence. In this way, safe and predictable instrumentation different root canal curvature measurement techniques and measuring the
to adequate apical preparation size that respects canal canal access angle in curved canals. Journal of Endodontics 31: 796-8
anatomy can be achieved. Hulsmann M, Peters O, Dummer P (2005) Mechanical preparation of
root canals: shaping goals, techniques and means. Endodontic Topics
10: 30-76
Conclusions McSpadden J (2007) Mastering endodontic instrumentation.
Chattanooga, Tennessee, USA. Cloudland Institute
• Controlled memory files have no shape memory effect,
Nagy CD, Szabó J, Szabó J (1995) A mathematically based
increased flexibility and fatigue resistance. As a result they classification of root canal curvatures on natural human teeth. Journal of
move passively inside the highly curved or double curved Endodontics 21: 557-60
Peters OA (2004) Current challenges and concepts in the preparation
canals guided only by the anatomy and not by the
of root canal systems: A review. Journal of Endodontics 30: 559-67
restoring force of other files Plotino G, Grande N, Mazza C, Petrovic S, Gambarini G, Testarelli L
• The TCA instrumentation technique minimises the time that (2010) Influence of size and taper of artificial canals on the trajectory of
NiTi rotary instruments in cyclic fatigue studies. Oral Surg Oral Med Oral
the files are under engagement inside challenging canals Pathol Oral Radiol Endod 109: e60-e66
and results in maintaining a continuous tactile feedback of Pirani C, Iacono F, Generali L, Sassatelli P, Nucci L, Lusvarghi M,
the anatomy throughout the whole instrumentation Gandolfi G, Prati C (2015) HyFlex EDM: superficial features,
metallurgical analysis and fatigue resistance of innovative electro
procedure discharge machined NiTi rotary instruments. International Endodontic
• Although the TCA technique can be used with all Journal [Epub ahead of print]
instrumentation systems available (rotary or reciprocation), Pedulla E, Lo Savio F, Boninelli S, Plotino G, Grande N, La Rosa G,
Rapisarda E (2015) Torsional and cyclic fatigue resistance of a new
controlled memory systems are the only ones where the files Nickel-Titanium Instrument Manufactured by electrical Discharge
can be pre-bent for easier negotiation of challenging cases Machining. Journal of Endodontics 42(1): 156-9
(abrupt curvatures, ledges and limited mouth opening Pruett JP, Clement DJ, Carnes DL Jr (1997) Cyclic fatigue testing of nickel-
titanium endodontic instruments. Journal of Endodontics 23: 77-85
patients) Roane JB, Sabala CL, Duncanson MG Jr (1985) The ‘balanced force’
• EDM files with controlled memory characteristics have concept for instrumentation of curved canals. Journal of Endodontics 11:
203-11
increased cutting efficiency and fatigue resistance. This
Schäfer E, Diez C, Hoppe W, Tepel J (2002) Roentgenographic
makes it feasible to use a single file instrumentation investigation of frequency and degree of canal curvatures in human
protocol for approximately 75% of human root canals. permanent teeth. Journal of Endodontics 28: 211-6
Shen Y, Qian W, Abtin H, Gao Y, Haapasalo M (2011) Fatigue
testing of controlled memory wire nickeltitanium rotary instruments. Journal
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May 2016
Coltene/Whaledent (2012) Hyflex CM [brochure]

VOL. 6, NO. 3 INTERNATIONAL DENTISTRY – AFRICAN EDITION 59