IEJ385.

fm Page 63 Friday, December 1, 2000 11:57 AM

CLINICAL ARTICLE
Oxford,
International
IEJ
Blackwell
0143-2885
2
1
34
GT
385
Buchanan
000
file selection
UKScience
Science,
Endodontic
Ltd,
Ltd 2000
Journal

The standardized-taper root canal

Graphicraft Limited, Hong Kong
00

preparation Part 2. GT file selection

and safe handpiece-driven file use

L. S. Buchanan
Dental Education Laboratories, Santa Barbara, CA, USA

Abstract

Buchanan LS. The standardized-taper root canal preparation Part 2. GT file selection and safe
handpiece-driven file use. International Endodontic Journal, 34, 6371, 2001.

Aim To present guidelines on GT file selection, and safe operation.

Summary It is not necessary to remove excessive dentine for effective root canal
preparation. GT files allow safe, standardized preparation, and should be selected to fit
the case in hand. Small Root canals should be prepared with 0.06 and 0.08 taper GT files,
whilst Large Root canals should be prepared with 0.10 GT or 0.12 Accessory GT files. The
greatest challenge is un-learning habits acquired from traditional instrumentation methods.
GT files should be used with light touch, and without updown pumping motions. Spin
speeds should be controlled below 300 r.p.m. for routine preparation. GT files are subject
to fatigue and should be tracked to avoid overuse. It is recommended that GT files are
discarded after the equivalent of five root canal preparations. For severe curvatures, GT
files should be single-case tools.
Key learning points
The standard GT file set comprises three instruments of 0.06, 0.08 and 0.10 taper. All
are size 20 at the tip, and have a maximum diameter of 1 mm.
Accessory GT files have a standard taper 0.12, and maximum diameter of 1.5 mm.
They are available in tip sizes 35, 50 and 70.
Large Roots are lower canines, upper anteriors, upper and lower single-rooted premolars,
palatal roots of upper molars and distal roots of lower molars. They should be pre-
pared with 0.10 GT or 0.12 Accessory GT files.
Small Roots are lower incisors, multirooted premolars, buccal roots of upper molars
and mesial roots of lower molars. They should be prepared with 0.06 or 0.08 GT files.
All GT files should be used with light force and at the correct spin speed.
GT files should be discarded after the equivalent of five root canal uses.

Keywords: file selection, root canal preparation, safety, variable taper files.
Received 30 March 2000; accepted 3 July 2000

Correspondence: Dr L. S. Buchanan, Dental Education Laboratories, 1515 State Street, Suite 16, Santa
Barbara, CA 93101, USA (fax: + 805 963 0946; e-mail: info@endobuchanan.com)

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Figure 1 Maxillary second molar with wildly curved canals. All four canals were shaped with
handpiece-driven GT files in less than 20 min.

Introduction

Suspension of disbelief

When I completed my postgraduate training at Temple University in 1980, it was a con-

sensus of opinion amongst endodontists that handpiece-driven root canal files were
dangerous instruments used only by expedient, sloppy dentists. Today, I do not know
of a single cutting-edge endodontist who is not shaping root canals with nickeltitanium
rotary files. What a difference 20 years can make.
In the last five years of the 20th century, handpiece-driven instrumentation took the
specialty by storm. If you doubt this statement, consider the following evidence.
Over the last five years the overwhelming majority of research studies have shown
the superiority of nickeltitanium handpiece-driven root canal files over traditional hand
instruments.
Endodontic educators are incorporating them into their curricula for undergraduate
dental students. The University of Tennessee, and Portland Oregons Health Sciences
University have already been using rotary files in their undergraduate dental clinics and
have seen shorter learning curves, higher student productivity in endo, and fewer
mishaps. Other undergraduate programmes, University of the Pacific in San Francisco,
and the University of Texas at Houston, are changing over to engine-driven nickel
titanium files this school year.
Thousands of practising dentists have now learned how to successfully use them in
practice. Tulsa Dental Products says that over six thousand dentists are active users,
and we at Dental Education Laboratories have run hands-on courses for more than
two thousand dentists ourselves.
With our own clinical research showing productivity increases of 500% achieved
concurrently with improved quality of shape (Fig. 1), this is truly an evolution of our small
field of clinical endodontics proportional to the introduction of the integrated circuit to
computer science.
Whilst it is said that change is opportunity, it is also said, as a curse, May you live in
interesting times. With all of this rapid change, there is a lot of confusion associated
with the design and use of this new technology. Fortunately, as engineers, manufacturers
and educators have gained experience with these new instruments, the techniques they
are used with have become more sophisticated, resulting in fewer files and fewer proce-
dural steps needed to ideally prepare a root canal.

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This is not to say that you will not hear lecturers and sales-people tell you that rotary
file use requires many steps and many different types of instruments to complete a root canal
preparation. Whilst it bothers me to hear dentists being misadvised that they need
nine or 10 instruments and 15 clinical steps to clean and shape a single root canal, it is
understandable considering the dramatic conceptual changes simultaneously occurring in
the field.
Two conceptual sea-changes now rolling through the specialty are responsible for this
confusion. The first is the growing appreciation for tapered shaping objectives over the apical
stop preparation. The second is the realization that we do not have to cut dentine to
clean root canals.
We know that the tapered root canal shaping objective allows dramatically greater latitude
in length control during shaping procedures, whereas the apical stop preparation is very
unforgiving of length determination errors (Buchanan 1991). It is also becoming better under-
stood that the more the apical prep is enlarged, the greater the chance for apical laceration.
As important, we now understand that you can clean root canals without cutting
any dentine. Baumgartner & Mader (1987) showed that when irrigated with just NaOCl,
uninstrumented canal walls were in fact cleaner than those abraded by files. In his
groundbreaking paper, Lussi et al. (1995) have shown exceptional cleaning of the root
canal systems of molars without any files being used at all.
Despite this research evidence and these clinical experiences, there remain educators
who still teach the apical stop preparation, leading many dentists to think that you have
to grind larger and larger files to the ends of root canals to get them clean and to create
adequate apical resistance form. Whilst using handpiece-driven nickeltitanium files to
create traditional canal shapes is a big step forward, I would suggest that you are still
using a lot of steps and a lot of instruments to create the same unpredictable shaping objec -
tive, albeit with greater efficiency. If you embrace the tapered preparation objective,
handpiece shaping of root canals with variably tapered nickeltitanium files is extremely
simple, requiring very few steps and very few instruments. The leap to tapered root
canal shapes is easy if you consider the following:
The apical diameters of root canals are more similar than different, generally in the
range 0.2 0.35 mm, so we only really need a few different tip diameters and tapers
on our instruments.
Tapered resistance form is not only ok, but is more predictable than the stop
preparation, primarily because it is forgiving of length determination errors.
Root canals are cleaned with irrigants, not by unnecessarily cutting dentine. This
releases us from nearly all risks of apical laceration.
With these concepts in mind, there are really only five technique areas that clinicians
must understand to successfully use this system of instruments in their own operatories. GT
file selection, safe methods for use of handpiece-driven GT files, techniques for Large
Root canals, techniques for Small Root canals, and techniques for shaping canals with
abrupt apical curvatures.
In this article, I will illustrate file selection and handpiece use, the other topics will
follow in subsequent articles.

GT file selection

The GT system of shaping instruments is small, comprising only six instruments

(Fig. 2a,b). Remarkably, these six files will definitively address a very broad range of
endodontic anatomy. This full set is divided into the standard GT series and the
0.12 accessory GT series. The standard GT series (Fig. 2a) includes the 0.10, 0.08 and
0.06 taper GT files and the 0.12 accessory GT series (Fig. 2b) includes the #35-0.12, #50 - 0.12,

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Figure 2 (a) The standard GT file set. All tip diameters are 0.2 mm and all maximum flute diameters
(MFD) are 1.0 mm. These files vary only by their tapers, which are (bottom to top): 0.10, 0.08, and
0.06 mm mm1. These will shape 90% of all canals. (b) The 0.12 accessory GT file set. All tapers are
0.12 mm mm1 and all MFDs are 1.5 mm. These files vary only by their tip diameters, which are (top
to bottom) 0.35, 0.50, and 0.70 mm. These files are for orifice flaring and for full length shaping of
large root canals with large apical diameters.

and #70 - 0.12 GT files. These instruments are manufactured by Tulsa / Dentsply (Tulsa, OK,
USA) for the US and by Maillefer/Dentsply (Ballaigues, Switzerland) for Europe, South
America and Asia.
Because these files create predefined shapes in root canals, the three parameters that
determine the final canal shape created by each file size are: the file tip diameter, the
taper of the file, and the maximum flute diameter (MFD). Therefore, to best understand
the process of file selection, it would behove the clinician to remember these dimen-
sions for each of the six file sizes. Come on, it is only six sizes and two variables.
The three files in the standard series (Fig. 2a) vary in taper, but have the same tip
diameters (0.2 mm) and the same MFD (1.0 mm). Conversely, the three 0.12 accessory
GT files (Fig. 2b) all have the same tapers and MFDs (1.5 mm), but vary by their tip dia -
meters (0.35, 0.5 and 0.7 mm).
It is important to understand that each taper size of the GT file set is only appropriate
to work in certain root forms. It would not be possible to jam a stiff 0.10 taper GT File around
a 45 bend in a thin molar root, nor would you even want to try because of the chance
that it would strip perforate the root. Neither would a 0.06 taper GT File create enough
apical resistance form in a large straight root canal with a large terminal diameter.
Therefore, the correct selection of GT files for each canal-form is critical, but simple as
it only requires an assessment of the curvature of the canal to be treated and the width
of its root. When you have made your choice of the GT file that will define the appropri-
ate final shape in a given canal, this is known as the Final Shaping Objective.
Begin by dividing the roots to be treated into Large Root and Small Root categories.
Large Roots are lower cuspids, maxillary anteriors, upper and lower single-rooted premolars,
palatal roots of upper molars and distal roots of lower molars. Small Roots are all of the

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Figure 3 Maxillary molar with moderate
curvature of the MB root. A 0.06 GT file was
chosen as the Final Shaping Objective for
the MB2 canal, an 0.08 GT File for the MB1
and DB canals, and a 0.10 GT file for the palatal
canal.
CLINICAL ARTICLE
Figure 4 Maxillary central incisor with large
apical diameter canal shaped with a single
#50 -0.12 GT File. Note the excellent control of
the filling material despite the relative lack of an
apical constricture. Positive apical architecture
was recreated with the 0.12 accessory GT file.

Table 1 GT file selection

Small Roots Large Roots

0.06 GT 0.08 GT 0.10 GT 0.12 accessory GTs

Thin &/or curved Most commonly used Large apical diameters

others: mandibular incisors, all two-and three-rooted premolars, buccal roots of upper
molars and mesial roots of lower molars.
Whilst it may seem simplistic to make this division, canals in Large and Small Roots
have distinctly different characteristics. Large Root canals typically have large diameters
in their coronal halves, apical diameters 0.20 0.35 mm, and relatively little canal curva-
ture. Small Root canals typically have narrow diameters in their coronal halves, apical
diameters 0.15 0.20 mm, and slight to severe canal curvatures.
Obviously, these morphologies require different shaping objectives, and different files
to create those shapes. It is a gift of nature that most curved canals have small apical
diameters, allowing their preparation to be accomplished with the most flexible GT files,
the 0.06 or 0.08 taper files. Most canals with large apical diameters are relatively straight,
allowing the introduction of the less flexible, but necessary 0.10 or 0.12 taper GT files.
To illustrate GT file selection, the case in Fig. 3 shows an example of each root-form
that would be ideally treated with 0.06, 0.08 and 0.10 tapers in the standard GT file
series. In this maxillary molar, a 0.08 taper was used for the MB1 and DB canals, a 0.06
for the MB2 canal, and a 0.10 taper file for the palatal canal. The case in Fig. 4 shows
an example of a Large Root canal that had a large apical diameter necessitating a 0.12
accessory GT file with a tip diameter of 0.5 mm (a #50 - 0.12).
To reiterate the general rules of GT file selection (Table 1); the 0.06 and 0.08 GT files
are small root files, the 0.10 and 0.12 GT files are large root files. The 0.08 GT file is the most
commonly used of the two, with the 0.06 GT file being chosen for thin and / or curved
small root canals. The 0.10 GT file is the most commonly chosen large root file, with the
0.12 accessory GT files being designed for large root canals that have large apical diameters.

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In addition to these general guidelines, there a number of nuance rules of GT file

CLINICAL ARTICLE

selection:
(1) Never use a file size that is stiff enough or large enough to laterally perforate or
needlessly weaken a root. Whilst the Large RootSmall Root rules work in 98% of the
cases, keep in mind that there are exceptions to every rule. A long, thin distal root of a
mandibular molar with a mid-root bend should be kept to a 0.08 taper GT shape for
safety, rather than the 0.10 taper shape that would typically be created. A mandibular
incisor with no curvature whatsoever should be kept to a 0.06 tapered shape if it is
extremely thin.
(2) Notwithstanding rule number one, more taper means more resistance form. In other
words, if you are treating a Small Root canal with normal root thickness and relatively little
curvature, you would nearly always choose the larger of the Small Root files, a 0.08 taper. In
a large root canal it is unusual to use a file smaller in taper than a 0.10 GT file.
(3) In Large Root canals with apices that are 0.3 mm in diameter, a 0.10 taper GT file
taken 1 mm long is the easiest way to create apical continuity of shape. In Large Root
canals with apical diameters larger than 0.3 mm, one of the 0.12 accessory GT files
(0.35, 0.5 or 0.70 mm diameter) is needed. Canals with apical diameters greater than
0.7 mm should be treated by other means (see point 4 below).
(4) In cases of immature, damaged, or resorbed apical canal-forms, different treatment
methods should be considered. If possible, a conventional approach is ideal, but whether
it is a surgical or non-surgical treatment plan, MTA (mineral trioxide aggregate-Dentsply /
Tulsa Dental) is the apical seal of choice due to its ease of placement and its amazing
biocompatability.

Safe rotary file use

I have heard quite a few comments regarding the superiority of electric vs. air drive
handpieces in endodontics, but have not really seen a significant difference in clinical
outcomes. Although electric handpieces are quieter than air-types, I have seen no differ-
ence in file breakage between the two types of motor. The important thing is to use a
handpiece that will deliver a preset, consistent r.p.m. (down to at least 300 r.p.m.). You
cannot adequately control the file speed with the foot control, you must have an air or
electric handpiece that does that for you.
Whilst torque limitation features available on the new electric handpieces may ulti-
mately prove to be an advantage in reducing the breakage factor, I have been using and
teaching rotary file technique with air-drive motors for more than six years, with no serious
difficulties in avoiding breakage. It is easy to see, however, that in the very near future
there will be electric handpieces that are much more sophisticated than their air- drive brothers.

Walking the dog

The file is mounted, the speed is set (Table 2), and the handpiece is brought up to the
appropriate speed before introducing the file into the canal. This full, preset speed is
used throughout the apically directed cutting action and the coronally directed with-
drawal of the file with no variation of that r.p.m. The spinning file is introduced into the
canal with a light touch until its cutting blades engage dentine and that pressure is
carefully increased until the file starts to walk into the canal.
With the unique flute angles of the GT files, there is no threading of files into canals,
so the handpiece method is different. An in and out pecking method of handpiece-
driven file use is taught for all other nickeltitanium rotary files, because they have tight
shank-end flute angles and create a tendency for the files to grab or thread into the canal.

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Table 2 Current GT file speed recommendations

Standard GT files
Canal shaping 300 r.p.m.
Removing gutta percha 1300 r.p.m.
0.12 accessory GT files
Canal shaping 500800 r.p.m.
Orifice flaring 500020 000 r.p.m.

Bouncing a handpiece-driven file in a root canal is not only less effective than a
smooth steady pressure, it is dangerous as it creates huge variances in torque stresses
on rotary files. Neither is circumferential filing effective, as these instruments cut best
when bound between opposite canal walls. The GT handpiece method is simply to insert
the spinning file, with a light, consistent pressure applied.
Usually within four seconds after handpiece-driven files start cutting in a canal, they
will stall-out and stop moving further into the canal and will just spin in place. Initially this
is because their flute spaces are full of debris. When flute spaces fill with debris, the
debris physically holds the cutting flutes away from the canal wall so they cannot cut
deeper into the canal. So just withdrawing the file and cleaning it will often allow the
same file to cut deeper into the canal. Conversely, pushing on the file after the flute
spaces are full will only invite breakage.
However, at some point during the initial crown-down procedure, a given file may stop
progressing deeper because it is binding too tightly along most or all of its length or
because it is being asked to cut around a canal curvature that it is too stiff to translate
around. Evidence of this situation is a lack of debris packing the flute spaces of a file that
has stalled. Again, in this case it will not be helpful or safe to push on the file.
Pushing on a handpiece-driven root canal file eventually overbinds the tip portion of
the file and, in a heartbeat, the handpiece just spins the shank end of the file off. Push-
ing on these rotary files is totally unnecessary, as a smaller file, used as the next part of
a crown-down routine, would always do better. If the 0.10 GT file gets balky in a canal,
go to the 0.08. If the 0.08 stalls out, pull out the 0.06. If the 0.06 GT file does not want
to go to length in a tight or severely curved canal, recapitulate through the crown-down
series again.

Avoiding the heartache of separation

Handpiece-driven shaping with nickeltitanium GT files, like all other techniques, is

unforgiving of certain clinical errors. Whilst the handpiece takes care of the file motion
and the geometry of each GT File predetermines the same preparation shape every
time, the operator is still solely in charge of avoiding file breakage. And in fact, I would
say that avoiding instrument separation is really the only significant clinical challenge of
this technique. Fortunately, it has been proven that file breakage can be virtually elimin -
ated with effective use strategies.
All files will break when used with ineffective technique, when used for too long, or
with too much force. Handpiece-driven nickeltitanium files are no different in that
regard, however, they are remarkably resistant to breakage when used as directed.
The easiest way to break a handpiece-driven, nickeltitanium file is with bad tech-
nique. For instance, when small files are used too early in the procedure, they bind den-
tine along much of their length, building up dangerous rotational stresses. Perhaps the
scariest but most likely example of this mistake would be using handpiece-driven files
in the same progression as hand files in the classical Apical Stop technique, taking the
20, 25, 30, and 35 files to full length early in the procedure.

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Figure 5 Maxillary molar with MB canal which is multiplanar in curvature. Consider bringing in a
fresh 0.06 GT file to cut the last, most challenging 1 2 mm.

Crown-down enlargement, using larger, stronger instruments before smaller ones, sig-
nificantly limits stresses on the more fragile rotary instruments, as they only cut near
their tips. GT files are always used in this manner, so that the files having greater tapers
can make room for the smaller taper GT files to follow. If you have not reached length
with the first crown-down series of file use, recapitulate through the series again.
The second easiest way to break handpiece-driven files is to push on a rotating file
that does not want to move more apically in a canal. When a file stalls in a canal, you
must disengage and pull it out. Training yourself to exercise the procedural discipline to
not push on these files is really the only tough part of this technique, but if you cannot
stop yourself from pushing on them, do not use handpiece-driven files.
For the standard GT files, the appropriate amount of pushing force that is safe, but
will still cut dentine effectively, is about what you would apply to a freshly sharpened
pencil. For the 0.12 accessory GT files, more pressure is safe because of their size, and
in fact you need to give these significantly more of a push to cut dentine.
Again, the key alternatives to pushing on a balky file are to step down in file size or to
recapitulate the sizes used already. Once in a while, due to manufacturing error, a new
file will be dull. If a new file will not cut apically, replace it with another file of the same
size and see what happens. If the second file cuts, put the dull one aside to sent back to
the manufacturer, so they can better tune their cutting edges.
Next on the list of file separation aetiologies is instrument fatigue. In straighter canals
they can easily shape five canal equivalents before being discarded. To keep track of
their use, line the files up in a sponge upon completion of the case and for each canal
equivalent, have the assistant run down this line of instruments with a permanent mark-
ing pen to make a hash mark on each of the file shanks. If the files were used in tough
canals, more than one hash mark might be appropriate for each canal treated.
Anatomic challenges significantly shorten the life span of these files, specifically canal
curvature, calcification, and dentinal hardness. One of my concerns about torque limita-
tion handpieces is that they do not take these factors into account. An amount of torque
that would be safe in a straight, large canal could be very dangerous in a tight, curved canal.
Because of this, I have found that the longer I use GT rotary files, the more value I see
in replacing used instruments with new. In fact, in severely curved canals they may be
single use instruments, as a single challenging canal can fatigue these instruments as
much as it would to shape five other less-curved canals. In fact, in canals with apically
accelerating curvature, or multiplanar curvatures (Fig. 5), it is wise to bring in a new 0.06
GT file to cut the last 1 2 mm, the most demanding length of the canal to prepare.
As with all endodontic files, use them with a light hand, and when in doubt, throw
em out.

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An unusual request

With all of that said, I am now going to make an unusual request. When you first take on
this new method of root canal shaping, please suspend disbelief and try the techniques
exactly as I describe them.
The main caution here is that the effective use of these rotary instruments entails a
totally different paradigm than with any other endodontic shaping technique. Most
often, clinicians take on the challenge of learning a new dental technology by trying to
understand it through their previous experience. It is the way we are neurally hooked
up, the way we try to make sense of new things. Unfortunately, that can be a serious
hindrance to learning.
Every endodontic educator I know says that it is easier to teach new technology to
a dental student, than to teach it to an experienced dentist. This is because dental
students do not have to un-learn anything; they have a clean hard drive. For those of
us, myself included, who have learned to use traditional instruments effectively, it can
be difficult not to use these new files with old methods.
This is not to say that these techniques are the end-all, or that they will not evolve
further. I am just saying that you can learn from those of us who have been using and
teaching rotary instrumentation for more than six years (remember, you become an
expert by making more mistakes than anyone else). The payback is that you will catch
on quicker, with fewer failures. Of course these techniques will evolve with time, usu-
ally because of suggestions from dentists who have first become experienced in the use
of these instruments. Stay tuned for further developments.

Conclusions

For safe and effective use, GT files should be correctly selected, and handled with light
touch and correct spin speed.
In the next article, I will illustrate, with 3D computer-generated graphics, the tech-
nique strategies needed to ideally shape large root canals with between one and three
GT files, usually in less than 3 min.

Acknowledgement

This article was first published in Europe in Endodontic Practice 3(4), 6 14 (September
2000), and is being reproduced with kind permission from FMC Ltd and Dental Education
Laboratories.

References

Baumgartner JC, Mader CL (1987) A scanning electron microscopic evaluation of four root canal
irrigation regimens. Journal of Endodontics 13, 147 57.
Buchanan LS (1991) Cleaning and shaping the root canal system. Chapter 7. In: Cohen S, Burns RC,
eds. Pathways of the Pulp, 5th edn. St Louis, USA: Mosby.
Lussi A, Messerli L, Hotz P, Grosrey J (1995) A new non-instrumental technique for cleaning and fill-
ing root canals. International Endodontic Journal 28, 1 6.

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