CONTINUING EDUCATION

Volume 34 No. 1 Page 138

The Stainless Steel Hand File:

Essential or Extinct?
Authored by Lisa Germain, DDS, MScD

Upon successful completion of this CE activity, 2 CE credit hours may be awarded

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does
not infer endorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment
and accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements.

CONTINUING EDUCATION

The Stainless Steel Hand

File: Essential or Extinct?

These instruments have .02 tapers, so it was a challenge to create

a gradually tapering funnel preparation. The use of hand files
in a push-pull or watch-winding motion did not accomplish the
3-D shaping goal outlined by Schilder1 that is necessary to allow
irrigants to flow throughout the canal system, nor did it
efficiently create the resistance form necessary for 3-D
compaction of the filling material.
Recognizing the limitations of the instruments available at
the time, Schilder1 described using stainless steel reamers in the
envelope of motion to create the desirable internal shape. In
essence, this was a rotary technique in its purest sense. This
adaptation stemmed from his realization that canal shapes were
influenced by the way an instrument was used in the canal, as
well as the type of instrument used. In order to accomplish the
biomechanical objectives of cleaning and shaping that were his
recommended cornerstone for successful endodontics, reamers
were the key.1

Effective Date: 01/01/2015 Expiration Date: 01/01/2018

About the Author

Dr. Germain graduated from Boston University School
of Graduate Dentistry with a specialty degree in
endodontics in 1981. She is a Diplomate of the
American Board of Endodontics, on the faculty of the
American Academy of Facial Esthetics, and a Fellow
of the International Congress of Oral Implantologists.
She maintains a private practice in New Orleans and
serves as the clinical director for DC Dental. She can be reached via e-mail
at [email protected].
Disclosure: Dr. Germain reports no disclosures.

STAINLESS STEEL K-FILES

Since stainless steel hand files are not considered part of a system,
it is misleading to think of these instruments as a relic of the past.
There are steps in root canal preparation where I find a hand file is
superior to prepare the canal prior to rotary usage.
There are several distinct phases in the preparation of a root
canal system:
1. Canal location (coronal patency)
2. Canal negotiation
3. Establishing apical patency
4. Creation of a glide path
5. Working length determination
6. Enlargement of the body of the canal.
Since I am rarely referred the type of cases where a .04/15 rotary
Ni-Ti will glide to the terminus without some work, I find that the
first 5 steps are best accomplished with a hand file. The last step is
where I find that a Ni-Ti rotary instrument is most useful.

INTRODUCTION
Reaming and Dreaming
Of late, I find myself frequently on the lectern discussing the
intricacies of the root canal system, the challenges of cleaning, the
art of shaping, and a dogmatic philosophy that guides my journey.
I teach, therefore, I am.
The question/answer period of any lecture can be interesting
and challenging. The goal is to teach students how the watch
works in addition to telling them what time it is without
overwhelming them. So, I try to give helpful, pertinent pearls,
which will advance both their knowledge and clinical skills.
However, when I am often asked, What instrument system do
you use? I am completely baffled as to how to answer.
If I answer, I dont use a system, I usually see them glance
at the crinkles beside my eyes and do a mental calculation to
figure out when I graduated from dental school. (Hello, Fred
Flintstonehave you met George Jetson?)
It is not that I have any doubts that Ni-Ti rotary instrument
systems have simplified canal preparation in a multitude of
ways; however, the type of instrument that I use at any given
time in a procedure is dictated by the canal anatomy and not by
the latest system du jour. The truth is, there is no one system that
does it all.
Back in the Stone Age, prior to the inception of Ni-Ti
rotary instruments, shaping a root canal system was done using
a series of stainless steel hand files and stainless steel reamers.

Coronal Patency
Once straight-line access to the canal orifice is achieved through
adequate access cavity preparation, assessing coronal patency
will confirm whether it is safe to introduce a rotary instrument.
Endodontic disease and calcific changes progress in a coronalto-apical direction. Therefore, if the canal is patent in the
coronal half, it will most likely open up all the way to the apex.
Coronal patency is established by working a No. 10 or No.
15 hand file about halfway down the canal. At this point,
introducing a rotary Ni-Ti instrument to pre-enlarge the coronal
and middle third of the canal can be efficacious.2

CONTINUING EDUCATION

The Stainless Steel Hand File: Essential or Extinct?

Canal Negotiation
a
b
Having established coronal patency
and pre-enlargement of the canal,
you now have nonbinding access to
the apical third of the canal with all
of its intricacies, anomalies, twists,
and turns. The ability to sense the
apical constriction by tactile
sensation is invariably increased
when a hand file can glide to that
area unimpeded due to the selective
removal of dentin in the upper
portion of the canal system. At this
Figure 1b. Postoperative image tooth No. 18 reveals a
stage, a hand file can give you Figure 1a. Preoperative image tooth No. 18
which does not show anatomic complexities in
bifid terminus located clinically with tactile sensation
information on canal anatomy that the distal root.
using a No. 15 K-file.
is easily missed when using a rotary
instrument. Endodontic finesse can only be achieved by misunderstood. In my opinion, it is the ticket to endodontic
developing tactile awareness with a hand file.3
success. Ask yourself how many times you have blocked
Prior to exploration, a K-file should be pre-curved so that it can yourself out when doing a root canal. If apical patency is
readily traverse subtle anatomical bends and access various maintained, blocking a canal and transporting the foramina
pathways that divide within the canal system. Using a rotary Ni- becomes a nonissue. It assures maintenance of a fluid glide path
Ti in a canal that suddenly divides is contraindicated due to a high and a consistent working length. If the glide path is not
probability of instrument separation. It is difficult to visualize this maintained, an apical plug of dentin mud will form. This will
type of canal system on a radiograph, but confirmation of its result in a shortened working length and lead to possible
presence can be achieved with a hand file. A hand file was used to perforations. In addition, thorough cleaning, shaping, and
negotiate through the extreme calcification as well as to locate the vertical compaction of the root canal space becomes impossible.
bifid terminus in the images shown in Figure 1.
To establish patency, a No. 8 or No. 10 hand file is used to
When a canal has an acute curvature, there is a greater risk of keep the apical constriction open by advancing 0.5 mm past the
ledging and/or blocking. This can be avoided by placing a small end of the root. The canal system should be filled with fresh
J-shaped bend in the apical 3 to 4 mm of a No. 10 hand file, then irrigating solution to prevent pushing debris apically. Using the
using it to scout the canal system. This simple adaption to the classic watch-winding motion, the file is passively advanced,
stainless steel file will allow negotiation in a canal as it makes never pushed or forced. If this is done after every working file
sudden directional changes.4 These difficult cases usually require to re-establish a glide path, your canal system will not become
that you use as many small files as you need to reach the terminus, blocked or ledged.
The idea is to probe gently into the apical control zone, then
along with copious irrigation.
pull
the instrument back and do all of the shaping on the inside.
A J-shaped bend can be accomplished in several ways. The
While
many fear that probing into this area will create
most rudimentary method is to use your fingertips and apply light
postoperative
pain, the opposite is actually true since you are not
pressure to curl the end of the file until you have the desired shape.
actively
filing
in the apical control zone.6 This is also the key to
Alternatively, a pair of cotton pliers can assist with creating the Jbend on the end of the file. These 2 methods are illustrated in achieving all of the biomechanical principles of cleaning and
Figure 2. The most precise way to create a smooth curvature is to shaping the root canal system, and the best way to keep the
use the Endo-Bender plier (Axis|SybronEndo) illustrated in Figure foramina as small as practical.1
3.5 It is important to create a curve, not a kink.
It is important to note that use of a chelating agent in this
step is not advisable. While these can lubricate the canal, they
Apical Patency
can also melt away the dentin without discrimination. This can
Apical patency is a concept both widely feared and frequently result in undesirable perforations or unnecessary enlargement

CONTINUING EDUCATION

The Stainless Steel Hand File: Essential or Extinct?

in the canal system, particularly in the apical third of the canal.
The idea is to follow the canal anatomy as it is and not create
your own.

Figure 2. The J-shaped

bend created in a hand file
with finger pressure and
with cotton forceps
suggesting 2 different
ways to adapt a hand file,
making it more efficacious
when negotiating curved
canals.

Glide Path
Nothing assures successful usage of Ni-Ti rotary instruments
more than the establishment of a glide path. It is a safety net. It
is a lifeline. But, it needs to be prepared with a hand file unless
the canal is already wide enough to accommodate a rotary
instrument.
West7 described the endodontic glide path as a smooth
radicular tunnel from canal orifice to physiologic terminus
(constriction of the foramina) with a minimal size of a super loose
No. 10 endodontic file. In a canal with minimal calcification,
establishing this pathway is simple. However, in a calcified canal,
it may need to be re-established with judicious use of small hand
files, copious irrigation, patience, and a very light touch.7 A
J-shaped bend on multiple small hand files proved invaluable in
maintaining the glide path in the case shown in Figure 4.

edges are almost perpendicular to the long axis of the instrument.

The reamer is not twisted as much, so it is most effectively used as
a carving tool rather than a cutting tool. The difference is illustrated
in Figure 5, where a .02 taper No. 35 reamer is placed next to a .02
taper No. 35 K-file for a side-by-side comparison. While a K-file is
used in a push-pull, watch-winding motion, or balanced force
technique, a reamer is used in rotational movement doing its work
on the outstroke in a clockwise direction.

Working Length Determination

If you ask 10 different endodontists where the canal terminates,
you will get 11 different responses. This question has become less
of an issue due to the popularity of electronic apex locators. These
devices measure impedance. They will not measure how close
you are to the canal terminus, although they will signal as you
get into the narrower canal spaces. The most accurate readings
for a working length are obtained by probing slightly past the end
of the root as you would when establishing patency, and pulling
the instrument back into the canal until the apex locator
indicates that you are at the apex.
The newest versions have a module that enables the unit to
function as a low-speed handpiece, as well as an apex locator
very Jetsonesque. But here is where I insist that my
Flinstonian technique of using a hand file is actually beneficial
due to increased tactile sensation. With a hand file, I can adjust
my file in nanometer increments up or down for a more precise
measurement.

Envelope of Motion
The technique for shaping with reamers is done using the
envelope of motion. A series of reamers are adapted by placing
a gentle curve on the fluted portion of the instrument. They are
placed into the canal in a step-back sequence, smallest to largest.
Figure 6 depicts a set of curved reamers with rubber stops placed
in a step-back sequence. The instruments are placed short of
maximum resistance, and removed while making a clockwise
rotation outward. Because the reamer is not as tightly wound
as a file, there are fewer points of contact, and it will only carve
away the portions of the dentinal wall that restrict this outward
rotation. The removal of these restrictions with each envelope
will allow the reamers to advance further down the root canal
system, thus creating concentrically enlarged internal cross
sections at every level.8 Figure 7 demonstrates the clockwise
rotation on the outstroke as well how the belly of the reamer
will plane the walls in successive concentric circles, only
removing the dentin that is obstructing the few contact points
on the instrument.

STAINLESS STEEL REAMERS

Dr. Schilders foresight was uncanny. Knowing that shaping the
canal a certain way was necessary to facilitate cleaning, he
developed a technique which created a rotary motion using the
very rudimentary tools that he had available at the time.1
Most stainless steel K-files and reamers are manufactured by
twisting a square or triangular pyramidal wire so that the cutting

Recapitulation
Upon completion of the sequence, and depending on the size of the
canal, it is common to recapitulate this procedure. This requires the

CONTINUING EDUCATION

The Stainless Steel Hand File: Essential or Extinct?

Figure 3. Endo-Bender pliers (Axis|SybronEndo), is shown creating a J-shaped bend in

apical 3 mm of a hand file.

Figure 4a. Preoperative image of tooth

No. 18 showing severe chamber and canal
calcification.

Figure 4b. Postoperative image tooth No. 18

after canal negotiation, shaping, cleaning, and
compaction, illustrating the benefit of placing a
J-shaped bend on the end of small hand files
to negotiate tight curved canals.

Figure 5. A No. 35 hand K-file and a No. 35

hand reamer illustrating how the file is more
tightly wound than the reamer.

Figure 6. A series of pre-curved reamers

prepared for use in a root canal system in a
step-back sequence.

Figure 7. An illustration of a reamer, when

used in the envelope of motion with a
clockwise rotation, will cut with the belly of
the instrument on the outstroke.

reintroduction of the sequence of reamers and the reapplication of

the envelope of motion, resulting in improved taper of the canal. It
is remarkable how much further the instruments go as the different
levels of the root canal space are blended into the ideal funnelshaped preparation.

and choose instruments from different systems to address

different clinical situations. The goal is to maximize results and
decrease procedural errors.9
Understanding the purpose and limitations of our tools is a key
ingredient to success in dentistry. All endodontic instruments have
the potential to separate, perforate, ledge, and block, whether they
are hand instruments or rotaries. There is no such thing as one
size fits all in our profession.
I would not want to practice endodontics the way I learned 30plus years ago. And using reamers in the envelope of motion is a
tedious, time-consuming endeavor. But, if my patient has a limited
opening and Ni-Ti rotaries do not fit, I have another way to shape the
canal. The plethora of instrument systems available give me more
options to work with to achieve my end result. George Jetson went
to work in a flying car. Fred and Barney had to use their feet to get
theirs started. But they all got to work on time. While I use Ni-Ti ro-

Rotary Instrument Systems

There are many different rotary systems to choose from, and
many still being developed. They differ significantly by factors
such as cross-sectional shape, points of contact, rake angle, tip
design, taper, and methods for use, to name a few. It is possible
to prepare a canal with a small terminus with almost all of the
systems available once a glide path is established. When the
apex is larger, the differences in the systems become more
important.
Many practitioners use a hybrid technique, in which they pick

CONTINUING EDUCATION

The Stainless Steel Hand File: Essential or Extinct?

taries in most instances, I am not completely ready to relegate all of
my reamers to a time capsule.
CLOSING COMMENTS
The use of hand files is essential in any endodontic shaping
technique. Ni-Ti rotary instrument systems are not a replacement
for the K-file. Canal location, negotiation, patency, glide path, and
working length determination are essential elements of modern
endodontic techniques. In most instances, these steps are best done
with the finesse and tactile sense that can only be achieved with a
hand file.
There are many endodontic instrument systems from which
to choose. Remembering that it is the operator, not the
instrument, that shapes the root canal space will help you to
avoid buying something that solves a problem that you do not
have.
While reamers are not widely used anymore, it is important to
recognize that they were the first instruments used to create rotary
motion within a canal system. If you look at it another way, Ni-Ti
rotary instruments have replaced hand reamers, but not hand files.
For the time being, the hand file is here to stay. (Yabba dabba doo!)F
REFERENCES
1. Schilder H. Cleaning and shaping the root canal. Dent Clin North
Am. 1974;18:269-296.
2. Brave D, Koch K. Apical and coronal patency. Dent Econ.
2002;92. dentaleconomics.com/ar ticles/print/volume92/issue-8/departments/real-world-endo/apical-and-coronalpatency.html. Accessed on December 9, 2014.
3. Stabholz A, Rotstein I, Torabinejad M. Effect of preflaring on
tactile detection of the apical constriction. J Endod.
1995;21:92-94.
4. Mounce R. Using hand files to their full capabilities: a new look
at an old yet emerging technology. Roots. 2012;3:12-20.
5. Buchanan LS. Case of the elusive MB2 canal. Dent Today.
2011;30:120-124.
6. Serota KS, Nahmias Y, Barnett F, et al. Predictable endodontic
success: the apical control zone. Dent Today. 2003;22:90-97.
7. West JD. The endodontic Glidepath: secret to rotary safety.
Dent Today. 2010;29:86-93.
8. Yu DC, Tam A, Schilder H. Patency and envelope of motiontwo
essential procedures for cleaning and shaping the root canal
systems. Gen Dent. 2009;57:616-621.
9. Walsch H. The hybrid concept of nickel-titanium rotary
instrumentation. Dent Clin North Am. 2004;48:183-202.

CONTINUING EDUCATION

The Stainless Steel Hand File: Essential or Extinct?

POST EXAMINATION INFORMATION
To receive continuing education credit for participation in this educational activity you must complete the program post
examination and receive a score of 70% or better.
Traditional Completion Option:
You may fax or mail your answers with payment to Dentistry Today (see Traditional Completion Information on following page).
All information requested must be provided in order to process the program for credit. Be sure to complete your Payment,
Personal Certification Information, Answers, and Evaluation forms. Your exam will be graded within 72 hours of receipt.
Upon successful completion of the post-exam (70% or higher), a letter of completion will be mailed to the address provided.
Online Completion Option:
Use this page to review the questions and mark your answers. Return to dentalcetoday.com and sign in. If you have not
previously purchased the program, select it from the Online Courses listing and complete the online purchase process.
Once purchased the program will be added to your User History page where a Take Exam link will be provided directly across
from the program title. Select the Take Exam link, complete all the program questions and Submit your answers. An immediate
grade report will be provided. Upon receiving a passing grade, complete the online evaluation form. Upon submitting
the form, your Letter of Completion will be provided immediately for printing.
General Program Information:
Online users may log in to dentalcetoday.com any time in the future to access previously purchased programs and view or
print letters of completion and results.
developing tactile awareness with a hand file.

This CE activity was not developed in accordance with

AGD PACE or ADA CERP standards. CEUs for this activity
will not be accepted by the AGD for MAGD/FAGD credit.

a. True

5. Nothing assures successful usage of Ni-Ti rotary

instruments more than the establishment of a glide path.

POST EXAMINATION QUESTIONS

a. True

a. True

b. False

b. False

a. True
3. Endodontic disease and calcific changes progress in
an apical to coronal direction.
a. True

b. False

7. It is not possible to prepare a canal with a small

terminus with almost all of the systems available once a
glide path is established. When the apex is smaller, the
differences in the systems become more important.

2. Since stainless steel hand files are not considered

part of a system, it is misleading to think of these
instruments as a relic of the past.
a. True

b. False

6. Because the reamer is not as tightly wound as a file,

there are fewer points of contact, and it will only carve
away the portions of the dentinal wall that restrict this
outward rotation.

1. Recognizing the limitations of the instruments

available at the time, Schilder described using
stainless steel reamers in the envelope of motion
to create the desirable internal shape.
a. True

b. False

b. False

8. All endodontic instruments have the potential to

separate, perforate, ledge, and block, whether they are
hand instruments or rotaries.

b. False

4. Endodontic finesse can only be achieved by

a. True

b. False

CONTINUING EDUCATION

The Stainless Steel Hand File: Essential or Extinct?

PROGRAM COMPLETION INFORMATION

PERSONAL CERTIFICATION INFORMATION:

If you wish to purchase and complete this activity

traditionally (mail or fax) rather than online, you must
provide the information requested below. Please be sure to
select your answers carefully and complete the evaluation
information. To receive credit you must answer at least
6 of the 8 questions correctly.

Last Name

(PLEASE PRINT CLEARLY OR TYPE)

First Name
Profession / Credentials

License Number

Street Address

Complete online at: dentalcetoday.com

Suite or Apartment Number

TRADITIONAL COMPLETION INFORMATION:

Mail or fax this completed form with payment to:

City

State

Zip Code

Dentistry Today
Daytime Telephone Number With Area Code

Department of Continuing Education

100 Passaic Avenue
Fairfield, NJ 07004

Fax Number With Area Code

Fax: 973-882-3622

E-mail Address

PAYMENT & CREDIT INFORMATION:

ANSWER FORM: VOLUME 34 NO. 1 PAGE 138

Examination Fee: $40.00 Credit Hours: 2

Please check the correct box for each question below.

Note: There is a $10 surcharge to process a check drawn on

any bank other than a US bank. Should you have additional
questions, please contact us at (973) 882-4700.

o I have enclosed a check or money order.

o I am using a credit card.

My Credit Card information is provided below.

o American Express o Visa o MC o Discover

1. o a. True

o b. False

5. o a. True

o b. False

2. o a. True

o b. False

6. o a. True

o b. False

3. o a. True

o b. False

7. o a. True

o b. False

4. o a. True

o b. False

8. o a. True

o b. False

PROGRAM EVAUATION FORM

Please complete the following activity evaluation questions.

Please provide the following (please print clearly):

Rating Scale: Excellent = 5 and Poor = 0

Course objectives were achieved.
Exact Name on Credit Card

Content was useful and benefited your clinical practice.

Review questions were clear and relevant to the editorial.

/
Credit Card #

Illustrations and photographs were clear and relevant.

Expiration Date

Written presentation was informative and concise.

How much time did you spend reading the activity and
completing the test?

Signature

What aspect of this course was most helpful and why?

This CE activity was not developed in accordance with

AGD PACE or ADA CERP standards. CEUs for this activity
will not be accepted by the AGD for MAGD/FAGD credit.

What topics interest you for future Dentistry Today CE courses?