Never Force a Hand File to the Apex

"Correlating what happens clinically with what is seen radiographically is essential for success."

Antonio Berto, DDS, Specialist in Endodontics
Dallas, TX


Case Study: GuttaCore University Challenge 1st Place Alumni Case – Handling an S-shape Curve on #14

Chief complaint: Extreme and increasing hot and cold sensitivity from the upper left.

Exam/diagnosis: Tooth No. 14 was hyper-responsive to cold with lingering pain upon removal of cold. The tooth presented with extensive decay into the pulp space (Fig. 1), was tender to percussion and responded normal to palpation. Radiographically, a mildly curved MB root, s-shaped DB root and long P root were noted (Figs. 1, 2). The periodontal ligament space and trabecular pattern were within normal limits.

Pulpal diagnosis: Symptomatic irreversible pulpitis. Periapical diagnosis: Symptomatic apical periodontitis.

Treatment options: Root canal treatment, no treatment or extraction.

Treatment: 1×1.8 ml carpule (36 mg) 2% Lidocaine, 1:100.000 epinephrine (0.018 mg) was administered via buccal and palatal infiltration. After rubber dam placement, access was made and caries were removed. Four orifices were located, MB1, MB2, DB and P.

The exploration of all systems was completed with #10 and #15 Lexicon K-files and copious irrigation of 6.15 % sodium hypochlorite. During the exploration phase, slight resistance was noted on MB1 and MB2 and moderated on the DB canal to obtained patency. The glide path was refined to length in all B canals with PathFile rotary files #13, #16, and #19.

“This step was vital to avoid procedural errors. Rather than trying to force hand files to reach the apex, a clinician should ask why the hand file cannot advance. Correlating what happens clinically with what is seen radiographically is essential for success,” said Dr. Berto.

Working length was determined using a Root ZX II apex locator. Patency was confirmed in all canal systems with a #10 Lexicon K-file. All buccal canals were subsequently instrumented with primary WaveOne reciprocating files, while a large WaveOne was used in the palatal canal. After shaping was completed, the EndoActivator was used to agitate the 6.15% NaOCl. After rinsing out the NaOCl with sterile water, the canals were irrigated with QMix 2in1 which was also activated. All canals were dried with paper points.

Obturation was completed using GuttaCore cross-linked gutta-percha core obturators to take advantage of the hydraulics and create a dense, three-dimensional seal on the areas where a heat source could not be delivered within a few millimeters of the apex.


“This step was vital to avoid procedural errors. Rather than trying to force hand files to reach the apex, a clinician should ask why the hand file cannot advance. Correlating what happens clinically with what is seen radiographically is essential for success,” said Dr. Berto. 


Dr. Antonio Berto has lectured both nationally and internationally, published over ten articles in peer reviewed journals and has won numerous endodontic awards, the most recent being the 2012 Rodriguez Carvajal Award for the best Clinical Case published on the official journal of the Spanish Association of Endodontics. Recently, several of his cases have been published in renowned Endodontic textbooks.

He is currently the Director of the endodontic section at the Advanced Education in General Dentistry Program at Baylor, where he teaches one day per week. The remainder of his time is devoted to his private practice, Highland Park Endodontics in Dallas, TX.

Dr. Berto serves as a Key Opinion Leader and Advocate for DENTSPLY Tulsa Dental Specialties. In addition, through his lectures and hands-on technique courses, he provides continuing education to many of the Dallas/Fort Worth general dentists. He has also served as President of prestigious associations and study clubs like the North Texas Hispanic Dental Association, DFW Metroplex Endo Society and Dallas CE Dental Study Club. And he is actively pursuing Diplomate status by the American Board of Endodontics.

Dr. Berto graduated with a dental degree (DDS) from the University of Madrid in 2005. He practiced general dentistry for one year and then completed his specialty training in endodontics at Baylor College of Dentistry in 2009 where he earned a specialty certificate in Endodontics.