SEMINAR ON

HAND FILES
ISO AND GREATER
TAPER


Submitted by:
Aditi Chandra
MDS- 2012
Department of Conservative
Dentistry and Endodontics
Introduction:

Hand instruments have been in clinical use for almost 100 years, and they still are
an integral part of cleaning and shaping procedures. A norm established by the
American Dental Association (ADA) and the International Standards Organization
(ISO) 13,131 sets the standards for broaches, K-type files and reamers, Hedstrm
files, and paste carries; however, the term I SO-normed instruments currently is
used mainly for K-files.
In 1989 American national standards institute (ANSI) granted the approval of
ADA Specification No. 28 for endodontic files and reamers. It established the
requirements for diameter length, resistance to fracture, stiffness etc.
In 1996, the specification No.28 was again modified.

Classification of endodontic instruments:

ISO-FDI grouped root canal instruments according to their method of use:
Group 1: hand use only, eg: K and H files, reamers, broaches etc.
Group 2: latch type engine driven: same design as group 1 but can be attached to
handpiece.
Group 3: drills or reamers latch type engine driven, eg: gates glidden, peeso
reamers.
Group 4: root canal points like gutta percha, silver points, paper points.

Grossmans classification:
Function Instruments
1. Exploring Smooth broaches and endodontic explorers
2. Dibriding or extirpating Barbed broaches
3. Cleaning and shaping Reamers and Files
4. Obturating Pluggers, Spreaders and Lentulospirals

Alloys used for manufacturing endodontic hand instruments:
1. Carbon steel
2. Stainless steel
3. Nickel- titanium

Carbon steel: They contain less than 2.1% carbon. They have high hardness than
stainless steel instruments. Disadvantage is that they are prone to corrosion and
rust hence cant be sterilized.
Eg: barbed broaches

Stainless steel: They are corrosion resistant. Contain 18% chromium, 8-10%nickel
and 0.12% carbon. Disadvantage is that they are stiff in nature, prone to fracture
and distortion.
Eg: K-file, H-file, reamer

Nickel titanium: They contain 55% nickel and 45%titanium. Their advantage is
that they have shape memory, super elasticity, low modulus of elasticity, corrosion
resistant, softer, good resiliency, biocompatible. Disadvantage is that they have
poor cutting efficiency and dont show any signs of fatigue before fracture, poor
resistance to fracture as compared to stainless steel.
Eg: NiTi hand files, profiles, protapers.

Manufacturing of hand instruments:
A hand operated file begins as a wire which is modified by 2 techniques:
1. By machining the instrument directly on the lathe, eg: H-file and NiTi files.
2. By 1
st
grinding and then twisting. The raw wire is ground into tapered
geometric blanks: square, triangular or rhomboid. These blanks are then
twisted counterclockwise to produce cutting edges.

Seto et al.
7
noted that grinding the flutes in files rather than twisting them "does
not improve the strength or ductility of the instrument . . . (and) may also create
more undesirable fluting defects." Since then, however, grinding has improved
and gained importance because most nickel-titanium instruments must be
machined, not twisted. Several recent studies have indicated that this type of
manufacturing does not weaken instruments. In fact, most studies indicate that
both manufacturing processes produce files that meet or exceed ISO standards.

Standardization of instruments by Ingle and Levine:
1. Instruments are numbered from 10-100. There is increase in 5units up to size
60and 10 units till size 100.
2. Each number should represent diameter of instrument in 100
th
of millimeter
at the tip.
3. Working blade shall begin at the tip (D
1
) and extend 16mm up the shaft (D
2
).
D
2
should be 0.32mm greater than D
1.

4. Instrument handles should be colour coded for easier recognition.
5. Instruments are available in the following lengths: 21mm, 25mm, 28mm,
30mm and 40mm.

Modification from Ingles standardization:
1. An additional diameter measurement point at D
3
is 3mm from the tip of the
cutting end of the instrument at D
0
(earlier referred as D
1
).
2. Tip angle of the instrument should be 75
0 +
_
15
0
.
3. Greater taper instruments (0.04, 0.06, and 0.08) have been made available.

Colour coding of endodontic hand instruments:

Size D 0 D 16 Handle color code
06 0.06 0.38 Pink
08 0.08 0.40 Gray
10 0.10 0.42 Purple
15 0.15 0.47 White
20 0.20 0.52 Yellow
25 0.25 0.57 Red
30 0.30 0.62 Blue
35 0.35 0.67 Green
40 0.40 0.72 Black
45 0.45 0.77 White
50 0.50 0.82 Yellow
55 0.55 0.87 Red
60 0.60 0.92 Blue
70 0.70 1.02 Green
80 0.80 1.12 Black
90 0.90 1.22 White
100 1.00 1.32 Yellow
110 1.10 1.42 Red
120 1.20 1.52 Blue
130 1.30 1.62 Green
140 1.40 1.72 Black








Tip Modifications:
Rationale of tip modification:
Powell et al. noted that each stainless steel files metallic memory to
return to a straight position , increases the tendency to transport or ledge
and eventually perforate curved canals.
This action takes place on the outer walls of the curved canals.
They pointed out that when the tip angle is reduced, the file stays
centered within the original canal and cuts all sides more evenly.
This modified tip file has been marketed as:
Flex-R File (Moyco/Union Broach)
Rounded tip file ( developed by Roane)

Traditional ISO 0.02 tapered hand files
Commonly used files:
1. K-File
2. K-Flex File
3. Flexo-File
4. Flex-R File
5. Hedstrom file
6. Safety H-File
7. S-File

File Design and Cross Sectional Shape:


Basic motions of instrumentation:


Filing / Rasping:
Indicates a push-pull action.
Instrument is placed into the canal at the desired length, pressure is exerted
against the canal wall.
The flutes rasp the wall as the instrument is withdrawn without turning

Reaming:
File is inserted and gently rotated in a clockwise direction with a mild apical
pressure till the desired length is reached.
Produces round tapered preparations.

Watch Winding motion:
File is rotated two or three quarter turns clockwise- counterclockwise and
retracted.
Instrument is cleaned, re-curved, re-lubricated and re-positioned.
Watch-winding is again repeated till the file is loose in position.

Balanced force:
Step 1: After pressureless insertion of a Flex-R or NiTi- Flex K-file, the instrument
is rotated clockwise 90 degrees using only light apical pressure.
Step 2: The instrument is rotated counterclockwise 180 to 270 degrees; sufficient
apical pressure is used to keep the file at the same insertion
depth during this step. Dentin shavings are removed with a characteristic clicking
sound.
Filing/
Raspin
g
Reaming

Watch
windin
g
Balance
d force
motion
Step 3: This step is similar to step 1 and advances the instrument more apically.
Step 4: After two or three cycles, the file is loaded with dentin shavings and is
removed from the canal with a prolonged clockwise rotation.


K-File:
Design & Structure:
K-files are manufactured from square or sometimes triangular steel wire that is
twisted to give the typical shape of a K-file. The angle between the long-axis and
the cutting blade is greater than in a reamer, and therefore preparation by a K-file
is effective both in rotary and filing motion.
The tip of the instrument is cutting which makes the K-file best suited for the
preparation of straight canals. Small K-files (ISO 06 - 15) can be also used in
curved canals without the risk of ledging. Small K-files are particularly good for
the initial preparation of very narrow canals.

Sizes & Codes:
K-files are produced in sizes 06 - 140, all with a taper of 0.02. K-file design is
identified by the square symbol on the handle.

Recommended use:
The K-file is suited for the preparation of straight canals. It prepares dentin
effectively both in filing motion (up and down) and when rotated. In slightly
curved canals the recommended techniques are continuous rotation when the
resistance is small and balanced force against greater resistance. Compared to
reamers, the use of continuous rotation is limited because of the screwing effect
typical of K-files.

Safety tips:
K-files can be rotated only using moderate pressure. Use of force, particularly
with smaller sized instruments may result in distortion of the helical structure and
ultimately in fracture. Balanced force technique and filing instead of continuous
rotation should be used with sizes 06 - 15 to minimize fracture risk. Each
instrument should be checked for symmetry by rotating it against an even
background before introducing it into the canal.




Difference between reamers and files:

FILES REAMERS
1. Cross Section Square Triangular
2. Area of cross section More Less
3. Flutes More (1 - 2/mm) Less (1/2 1/mm)
4. Flexibility Less More
5. Cutting motion Rasping (Push and Pull) Rotation and
Retraction
6. Preparation shape Usually Ovoid Round


FlexoFile:
Design & Structure:
Flexo files are manufactured from triangular steel wire that is twisted to give the
typical profile of a K-file. The angle between the long-axis and the cutting blade is
bigger than in reamers, which is why preparation by flexo file is effective both in
rotating motion and in filing motion (up and down movement). The tip of the
instrument is non-cutting ('bat-tip') which makes the flex file well suited for the
preparation of evenly curved canals without the risk of ledge formation.
Sizes & Codes:
Flexo files come in sizes 15 - 40, all with a taper of 0.02. It is identified by the
square symbol on the handle. Flexo files can be best distinguished from normal K-
files by the size code at the top of the instrument: in flexo files the color of the
number is the same as the color of the handle.

Recommended use:
Flexo file is suited for both straight canals and slightly curved canals. The flexo
file prepares dentin effectively both in filing motion (up and down) and when
rotated. In slightly curved canals the recommended techniques are continuous
rotation when the resistance is small and balanced force against greater resistance.
Use of continuous rotation is limited as compared to reamers because of the
screwing effect typical of K-files.

Safety tips:
Flexo files can be rotated (balanced force) only using moderate pressure. Use of
force, particularly with smaller sized instruments, may result in distortion of the
helical structure and ultimately in fracture. Every instrument should be checked for
symmetry by rotating it against an even background before introducing it into the
canal.

Golden Mediums:
The K-Flexo Files Golden Mediums are identical to the K-Flexo Files except that
the diameters have intermediate values compared to those of the ISO standard. The
Golden Mediums are only available in ISO diameters 12, 17, 22, 27, 32 and 37; the
lengths remain 21, 25 and 31mm.Their use is recommended for long and calcified
or curved canals where the passage from a 10 file to a 15 file or from a 15 to 20
file may be difficult; the use of intermediate diameters enable the operator to reach
the working length earlier and with less risk of complications.

K-Flex File:
The K-Flex file represents the first attempt to make a hybrid instrument, able to
integrate the force and versatility of a K-File with the cutting aggression of a
Hedstroem file. The K-Flex has a romboidal cross-section with 2 acute angles and
2 obtuse angels. The 2 acute angles help in improving cutting efficiency and
sharpness of the instrument. The 2 obtuse angles provide more space for debris
removal. Also the decreased contact of the instrument with the canal walls
provides more space for irrigation. They are used in filing and rasping motion. It is
only available in stainless steel with the same diameters and lengths as K-Files.
TripleFlex Files:
They are made of stainless steel and triangular in cross section. They have more
flutes than reamers but less than K-files. They are more aggressive and flexible
than regular K- style instruments.

Flex-R- Files:
They are made by removing the sharp cutting edges from the tip of the instrument.
The non cutting tip enables the instrument to traverse along the canal rather than
gouge into it. This design reduces the ledge formation, canal transportation and
other procedural accidents when used with balanced force technique. They are
triangular in cross section which provides it flexibility to be used in curved canals.
They are made of NiTi and cut during anti clockwise rotary motion.


Hedstroem File:
Design & Structure:
Hedstroem files are manufactured from round steel wire by grinding. The angle
between the long-axis and the cutting blade is close to right angle, which is why
preparation by Hedstroem files is effective only when using a filing motion (up and
down movement).

Sizes & Codes:
Hedstroems come in sizes 08 - 140, all with a taper of 0.02. H-file design is
identified by the circle symbol on the handle.

Recommended use:
Hedstroem can be used both in straight canals and curved canals. The hedstroem
prepares dentin effectively only when using a filing, up and down motion. In
curved canals, files (sizes 20/25 and bigger) must be pre-curved to correspond to
the shape of the curve. H-files must always fit loosely in the canal to avoid risk for
fracture. This is easily obtained by selecting a smaller H-file after each rotating
instrument. Small sizes up to #25 can be used down into full preparation length
while bigger sizes are often used 1 - 3 mm short.

Safety tips:
Hedstroem files show a greater risk for fracture than reamers and K-files if used in
a wrong way. However, correctly used H-files rarely fracture. Hedstroem must
always fit loosely in the canal and they must never be rotated. In curved canals
Hedstroemfiles are pre-curved to correspond to the shape of the canal. Before
introducing them into the canal, all Hedstroem files must be inspected for possible
earlier damage to the instrument and discarded immediately if an asymmetry in the
cutting area is found.


Safety H-File:
This file has non cutting safety side along the length of the blade which reduces the
chances of perforation; the non cutting side prevents lodging of the canals.

S-File:
The S-File is obtained by micromachining/ grinding a nickel titanium wire with
ISO .02 taper having S- configuration in cross-section, hence making it stiffer
than H-File. They have a constant angle of the spirals throughout its working
length and a spiral depth which increases from the tip to the handle. They have 2
spirals for cutting blades, forming double helix design. They have good cutting
efficiency in either filing or reaming action thus can also be classified as a hybrid
design.

C+ Files:
The C+ Files are files devised to facilitate the location of the canal orifices and the
initial exploration of calcified canals. Available in ISO diameters 8, 10 and 15 with
lengths of 18, 21 and 25 mm, the C+ Files show a characteristic resistance to
deformation. Derived from a quadrangular cross-section, this allows the operator to
exert 143% more pressure during insertion into a canal than would deform a K-File
of corresponding size. The C+ Files have depth gauge black markings along their
shaft, which indicate 18, 19, 20, 22 and 24 mm from the tip, aiding the positioning
of the silicone stop and allowing an accurate check of the insertion depth of the
instrument. The pyramidal tip of the C+ Files favors the penetration in calcified
canals, while their metallic surface has been subjected to an electropolishing
process, which makes them particularly smooth, thereby reducing the friction
against the canal walls and the accumulation of debris in the spaces between the
blades.

Unifile:
The Unifile has a cross-section in the shape of an Sobtained by machining a
double helix on the long axis of a round wire. The depth of the spirals is less than
that of the H-File with consequently higher strength.The Unifiles are available in
the ISO diameters from 15 to 80 and with lengths 21, 25 and 31 mm.

NiTi-Flex-Files:
Design & Structure:
NiTi-flex-files are manufactured from nickel-titanium wire that is ground to give
the typical profile of a K-file. The angle between the long-axis and the cutting
blade is bigger than in reamers, and therefore preparation by NiTi-flex-file is
effective both in rotating motion and in filing motion (up and down movement).
The tip of the instrument is non-cutting ('bat-tip') which makes the NiTi-flex-file
well suited for the preparation of curved canals without the risk of ledge formation.

Sizes & Codes:
NiTi-flex-files come in sizes 15 - 60, all with a taper of 0.02. Design is identified
by the square symbol on the handle. NiTi-flex-files can be best distinguished from
normal K-files by the code that NiTi-flex-files is printed with two colors.

Recommended use:
NiTi-flex-file is suited to be used both in straight canals as well as in curved
canals. The NiTi-flex-file prepares dentin both in filing motion (up and down) and
when rotated. In curved canals the recommended techniques are continuous
rotation when the resistance is small and balanced force against greater
resistance. Use of balanced force instead of continuous rotation is easier because of
the K-file design, which causes a screwing effect in continuous rotation. The use of
filing motion in curved canals can cause transportation and ledging, and is not
recommended.

Safety tips:
NiTi-flex files can be rotated only using moderate pressure. Use of force may
result in fracture. NiTi-flex files are super-elastic and always return to their
original shape (= elastic memory), which makes it difficult or impossible to detect
weakened structure by visual observation. Fracture risk is best controlled by
correct use and by using the instrument no more than ten times.



HAND INSTRUMENTS WITH GREATER TAPER

Hand GT Files:
The Hand GT Files 6,7 devised by Dr. L.S. Buchanan, are instruments in NiTi
with greater taper obtained by machining contrary to the Rotary GT Files and
Profiles which have radial lands type blades, the Hand GT Files have sharpened
blades which are machined in an counter-clockwise direction with a pitch (number
of spirals per mm) and helical angle (blade inclination) that is variable from the tip
towards the handle. In particular, the number of spirals are higher and the cutting
angle wider near the apical part of the instrument, while coronally the spiral
number is reduced and the angle becomes narrower. Clinically the apical part
functions like a K-File with good torsional strength and tactile perception of the
canal, while the coronal part functions like a reamer reducing the tendency to
screw in and favouring the elimination of debris. The Hand GT Files also have the
blade direction counter-clockwise, that is opposite to other hand instruments and
therefore to be able to cut they must be rotated in a counter-clockwise direction. It
is possible to use the Hand GT Files with the watch winding movement but in the
opposite direction or using the balanced force technique inverted, while their filing
efficiency is modest (push and pull). The GT Hand Files consist of four instuments
with a fixed diameter at the tip of 0,20 mm, a maximum diameter of the blades of
1.00 mm and a taper respectively of .06, .08, .10 and .12; as a consequence of this
characteristic, the length of the cutting part of the GT Files reduces from 13.5 mm
for the .06 taper to 6.7 mm for the .12 taper.6,7 The GT Hand Files have a non-
cutting tip, ergonomic pear shaped handle with a diameter of 6 mm and depth
gages that is dark markings placed along the shank at 18, 19, 20, 22 and 24 mm
from the tip, that facilitates the positioning of the silicone stop and allows accurate
control of the insertion depth of the instrument. The colours of the handle (white
for GT .06, yellow for GT .08, red for GT .10 and blue for GT .12) do not follow
the ISO system but are for indicating the progression of the taper of the
instruments. The GT Hand Files can be used on their own as the only instruments
for shaping or sequentially with hybrid instrumentation together with hand
instruments or following rotary instruments such as GT Rotary Files, Profiles or
the ProTapers.11 They are particularly useful to bypass the ledges and in the
presence of canals with a severe apical curvature due to the possibility of
precurvature with the appropriate instruments such as the Endobender.



Profiles .04 hand files:
The ProFile system was introduced by Dr. Ben Johnson in 1994.
Profiles .04 Hand Files 11,28 are NiTi hand instruments obtained by machining;
available in ISO diameters from 15 to 80, the Profile .04 Hand Files have a taper
that is twice that of traditional hand files with a diameter that increases from the tip
to the handle by 0.04 mm per mm of length. The design of the blades and tip of the
hand Profiles is identical to the rotary Profile; the blades infact are flat radial lands
type and the tip is rounded and non cutting. The correct method of using the
ProFiles manually is rotation in the canal with light pressure without forcing the
instrument. Complete rotation of 360 or more is permissible but it is also possible
to use the balanced force technique. The Profile Hand instruments can be used as
finishing instruments in complex cases where the use of rotary instruments could
be hazardous (confluent canals, sharp apical curvatures) or also as the only
instrument for root canal shaping.


Pro Taper hand files:
The ProTaper NiTi files represent a revolutionary generation of instruments for
shaping root canals.

Design and Structure:
ProTaper instruments are prepared from round nickel-titan wire by grinding.
Crosssection of the instruments shows a triangular structure with three cutting
points and no radial lands. ProTaper instruments have a non-cutting tip that guides
the instrument in the canal and reduces the risk for ledge formation.The convex
triangular cross-section which reduces the contact area between the file and
dentine. This greater cutting efficiency has been safely incorporated through
balancing the pitch and helical angles. A progressively tapered file,it engages a
smaller zone of dentine which reduces torsional loads, file fatigue and the potential
for breakage. It clinically serves to improve flexibility, cutting efficiency and
typically reduces the number of recapitulations needed to achieve length,
especially, in tight or more curved canals.

Sizes & Codes:
ProTaper instruments are manufactured in six sizes: Three shapers and Three
finishing files:

SX file (no color ring) is 19 mm long and exhibits nine increasingly larger tapers
ranging from .035 to .19 between D1 and D9, and a fixed .02 taper between D10
and D14.
S1file (violet) has a tip diameter of 0.185 mm and exhibits twelve increasingly
larger tapers ranging from .02 to .11 between D1 and D14.
S2 file (white) has a tip diameter of 0.20 mm and exhibits nine increasingly larger
tapers ranging from .04 to .115 between D1 and D14.
F1 file (yellow) has a tip diameter of 0.20 mm. The taper is .07 between D1 and
D3.
F2 file (red) has a tip diameter of 0.25 mm. The taper is 0.8 between D1 and D3.
F3 file (blue) has a tip diameter of 0.30 mm. The taper is 0.9 between D1 and D3.

The Finishing files have decreasing tapers from D4-D14. This design feature
serves to improve flexibility, reduce the potential for dangerous taper-lock, and
prevent the needless over-enlargement of the coronal two-thirds of a root canal.


Manual ProTaper Handle Motion:
a. Use a clockwise motion and gently rotate the handle until it is just snug. When
the handle is snug, the flutes of the file are lightly engaging dentin.
b. Cut dentin by rotating the handle clockwise while simultaneously withdrawing
the file.
c. If over-engaged, disengage the file by rotating the handle counterclockwise 45-
90 degrees while concomitantly withdrawing the instrument to prevent any given
file from inadvertently advancing deeper into the canal.
d. Repeat the handle motions until desired length is achieved.
e. Depending on the length, curvature, and diameter of any given canal, it may
require one or more passes to carry a file to the desired depth.

Safety tips:
Only light pressure can be used with the instruments, never force them. ProTaper
is an extremely effective instrument that cuts dentin smoothly. Instruments must
therefore be constantly cleaned and inspected. Distorted instruments must be
discarded immediately. ProTaper is not used with a pecking motion, but lightly
pressed forward in the canal.


Advantages of Greater Taper files over ISO hand files:
Traditional stainless-steel ISO 0.02 tapered instruments by hand very often
results in iatrogenic damage to curved root canals like apical transportation,
ledging, perforation, zipping and instrument fracture.
A further disadvantage is their tendency to create narrow canal shapes which
makes effective access for irrigants more difficult.
Less apical extrusion of debris occurs with greater taper files.
The major advantage of Greater Taper files is its ability to retain flexibility
with increased taper.
Fewer instruments are used during preparation with greater taper files.
Less time needed for preparation of root canals with greater taper.

Instrument fracture:
Sotokawa studied discarded instruments and indicated metal fatigue as the culprit
in breakage and distortion.
He classified the types of damage to instuments as follows:





Methods of cleaning endodontic files:
An essential requisite for sterilization is that the instruments be visibly clean and
free of all obvious debris. If saliva, blood, tissue or dental materials are not
removed, they may insulate the underlying microorganisms from sterilizing agent
or disinfecting chemical or may inactivate some disinfecting chemicals. Many
methods have been advocated for cleaning endodontic instruments: cotton rolls,
gauze ,sponges, hand brushes, rubber dam, clean-stand and ultrasonic cleaner.
Some of them are used dry or soaked with disinfecting or antiseptic substances
such as 70 per cent alcohol. The gauze and sponges are probably the most
frequently used methods for cleaning intracanal instruments.
Type 1
Bent instrument
Type 2
Stretching or
straightening of twist
contour
Type 3
Peeling off metal at
blade edges
Type 4
Partial clockwise twist
Type 5
Cracking along axis
Type 6
Full fracture
Methods of sterilizing endodontic files:





Conclusion
Current NiTi hand preparation procedures that use files with a greater or variable
taper are a substantial improvement over instrumentation with 0.02 tapered
stainless steel files particularly when used in curved root canals.
These newer instruments produce canals with a better shape, using fewer
instruments and in a shorter time. Such instruments are also a most useful adjunct
to rotary canal preparation.
However the literature is replete with reference to the superiority of one
instrument over all others. Briseno stated that Regardless of the instrument type,
none was able to reproduce ideal results; however clinically acceptable results
could be obtained with all of them.









Autoclave
Dry heat
oven
Chemical
vapour
Glass bead
sterilizer