SYSTEMATIC REVIEW

Assessment of the Effectiveness of Supplementary Methods for

Residual Filling Material Removal Using Micro-computed Tomography:
A Systematic Review and Meta-analysis of In Vitro Studies
Xueqin YANG, Jing LAN, Mengzhen JI, Chialing TSAUO, Yuan GAO, Ling ZOU

ABSTRACT
A systematic review and meta-analysis were conducted to evaluate the effectiveness of auxiliary methods
in removing residual filling material (RFM). This systematic review has been registered with the International
Prospective Register of Systematic Reviews (registration number CRD42020197482). A comprehensive litera-
ture search was conducted to identify relevant articles in electronic databases (PubMed, Embase, Cochrane)
from January 2005 to March 2021. In vitro studies investigating or comparing at least one type of supplemen-
tary method or technique were included. A total of 26 studies were selected from the 239 records obtained
after screening the databases. Ten of the included studies were suitable for meta-analysis. Strong evidence
showed that ultrasonically activated irrigation (UAI) [SMD (95% CI): -0.52 (-0.88 to -0.16, P=0.266)] and XP-
Endo Finisher R (XPR) [SMD (95% CI): -0.55 (-0.89 to -0.20, P=0.136)) contributed significantly to increase
the removal procedure, and XPR has no significant superiority over UAI [SMD (95% CI): 0.36 (-0.12 to 0.84,
P=0.994)]. Strong evidence was found to support the increased cleaning efficiency of the supplementary use
of the Gentle Wave system, laser irradiation, XP Endo Finisher, and self-adjusting file. In contrast, conflicting
evidence was found to support the use of sonic to improve the removal of RFM, and limited evidence was
found to support the efficiency of Tornado Brush. Under in vitro conditions, UAI and XPR increase the removal
of RFM from the root canal system during retreatment procedures.
Keywords: Auxiliary methods, micro-computed tomography, residual filling material, retreatment, root canal

Please cite this article as: Yang X,

Lan J, Ji M, Tsauo C, Gao Y, Zou L.
HIGHLIGHTS INTRODUCTION
Assessment of the Effectiveness Retreatment is defined as "a pro-
of Supplementary Methods
for Residual Filling Material • Both UAI and the XPR increase the removal of RFM cedure to remove the root canal
Removal Using Micro-computed from the root canal system during retreatment pro- filling material from the tooth, fol-
Tomography: A Systematic Review cedures. lowed by cleaning, shaping and
and Meta-analysis of In Vitro obturating the canals" by the AAE
Studies. Eur Endod J 2022; 7: 178-86 • Supplementary use of GW, LI, XPEF, and SAF in-
Glossary of Endodontic Terms (1).
creased the cleaning efficiency of retreatment pro-
From the Department of Ideally, during the process of root
cedures.
Endodontics (X.Y., M.J., C.T., Y.G., canal retreatment, all existing fill-
L.Z. zouling@scu.edu.cn), State • The use of sonic to improve the removal of RFM ing material should be removed
Key Laboratory of Oral Diseases need more support. (2). The remaining root canal filling
& National Clinical Research
Center for Oral Diseases, West material (RFM) will lead to the re-
China Hospital of Stomatology, infiltration of residual microorgan-
Sichuan University, Chengdu, isms and their toxins between the sealant and the root canal wall, leading to periapical tissue
China; Department of Stomatology
(J.L.), The First People's Hospital of
inflammation and affecting the long-term effect of root canal retreatment (3-6). Therefore, the
Neijiang, Neijiang, China evaluation of the clearance efficiency of root canal fillings can indirectly predict the effect of root
canal retreatment.
Received 17 August 2021,
Revised 08 March 2022, Traditionally, both destructive and radiographic methods are used for the evaluation of RFM, such
Accepted 30 May 2022 as tooth splitting and microscopic assessment of the structures, two-dimensional periapical ra-
Published online: 12 September 2022 diography, cone-beam computed tomography, and micro-computed tomography (micro-CT)
DOI 10.14744/eej.2022.22932 imaging (7-10), among which micro-CT is considered a research method with the advantage of
high-resolution (11).
This work is licensed under
a Creative Commons
Attribution-NonCommercial
In 2017, a systematic review discussed the effectiveness of different instrumentation procedures
4.0 International License. in removing root-canal filling materials and concluded that the instrumentation protocols can-
EUR Endod J 2022; 7: 178-86 Yang et al. Effectiveness of supplementary methods for RFM 179

not completely remove RFM from the root canal system (12). • Comparison (C): Removal of root canal filling material us-
Micro-CT studies have shown that the mean percentage of ing either a reciprocating single- or rotary multi-instru-
RFM ranges from 43.9% to 0.02%, with most studies report- ment system without a supplementary step;
ing values less than 10% (13, 14). Nonetheless, 0.5% RFM has
been suggested as a cutoff point to reflect ''effective canal • Outcome (O): Assessment of the volume of the RFM in the
cleaning'' (15). Numerous studies have shown that even when root canal after a supplementary step;
using nickel-titanium rotary or reciprocating instruments with
various designs and alloys, the complete removal of root canal • Study (S): In vitro comparative study.
filling material is almost impossible (13, 16-20). Therefore, sup-
plementary techniques to enhance filling material removal The main search terms were "micro-CT", "root canal filling",
and canal cleaning have been proposed as an adjunct to me- "RFM", and "removal". The language was restricted to English.
chanical retreatment (21-24). An example of the final search strategy is presented in Table
1. Moreover, three main endodontic journals, the Journal of
Numerous studies have investigated supplementary methods Endodontics, International Endodontic Journal, and Australian
for removing RFM from the root canal system after instrument Endodontic Journal, were manually searched for articles that
preparation. In addition, some studies have evaluated the po- were not found in the databases but were in the press. After
tential of irrigation methods, such as ultrasonically activated removing duplicate articles, the references of the selected pa-
irrigation (UAI) (19, 21-23, 25-30), sonically activated irrigation pers were further searched to obtain pertinent articles.
(SAI) (31), apical negative pressure (ANP) irrigation using the
EndoVac system (Discus Dental, Culver City, America), and a Eligibility criteria
side-vented needle (ProRinse; Dentsply Sirona, York, America)
Inclusion criteria were as follows:
(32), and laser-activated irrigation (LAI) (27, 33, 34). The effec-
1. In vitro studies performed root canal retreatment proce-
tiveness of different supplementary files along with an irriga-
dures on mature permanent human teeth.
tion solution (15, 23, 24, 29, 35-41) and endodontic brushes
(15) has also been assessed in past studies. Despite abundant
2. Studies comparing the amount of RFM before and after us-
literature reporting on the efficacy of these techniques, out-
ing supplementary methods.
comes are often conflicting. This indicates the need for a sys-
tematic review of the literature to elucidate the effectiveness
3. Micro-CT was used to evaluate the amount of RFM.
of supplementary cleaning methods. Therefore, this system-
atic review aimed to evaluate the effectiveness of supplemen- Exclusion Criteria were as follows:
tary methods in removing RFM in addition to instrumental 1. Studies performed on artificial teeth or animal teeth.
preparation during root canal retreatment.

MATERIALS AND METHODS 2. Studies without micro-CT data of the RFM after the first re-
moval.
Protocol and registration
The study protocol was registered in the PROSPERO interna- 3. Reviews, letters, opinion articles, and conference abstracts.
tional prospective database of systematic reviews under the
registration number CRD42020197482. This systematic review Study selection process
was prepared following the guidelines of the Preferred Report- Two trained reviewers (X.Y and J.L) independently screened the
ing Items for Systematic Reviews and Meta-analysis statement titles and abstracts, followed by the full texts to select studies ac-
(http://www.prisma-statement.org). cording to the inclusion criteria mentioned above and exclusion
criteria. Any disagreements between the two reviewers were
Literature search strategy resolved by discussion with a third experienced reviewer (C.T.).
An electronic search was conducted in the PubMed, Embase,
and Cochrane library databases (January 2005-March 2021). Data extraction and synthesis of evidence
"Do supplementary steps after a reciprocating single- or ro- Two reviewers (X.Y. and J.L.) worked independently to extract
tary multi-instrument system preparation during the process data from the included articles. Any reviewer disagreements
of root canal retreatment improve the removal of the RFM?" were resolved by discussion with a third reviewer (C.T.). The
was the interest of this review. data extracted included specific details about the authors,
populations, interventions, study methods, and main find-
PICOS question ings. In addition, data extraction was performed to assess the
The population, intervention, comparison, and outcome impact of supplementary methods on removing RFM. Finally,
(PICO) strategy used for the structured review question were a meta-analysis was limited to those where outcomes were
based on the PICOS strategy (PRISMA-P 2016) as follows: quantitatively presented as means and standard deviations.

Population (P): Extracted mature human teeth; Quality Assessment (Risk of Bias)
The revised Cochrane risk-of-bias tool (RoB 2.0) for randomised
• Intervention (I): Removal of root canal filling material using trials was used to evaluate the risk of bias arising from the
either a reciprocating single- or rotary multi-instrument following domains: sample size calculation, randomisation
system with a supplementary step; process, standardisation of the anatomical morphology of
180 Yang et al. Effectiveness of supplementary methods for RFM EUR Endod J 2022; 7: 178-86

TABLE 1. Example of the search strategy (PubMed) as 'uncertain', leading to contacting the authors for more infor-
No Search strategy Results
mation allowing us to finally classify their study as 'low', 'mod-
erate', or 'high' risk of bias.
1 (“Microcomputed tomography”) OR 21578
(“Micro-computed tomography”) OR Meta analysis
(Micro CT) OR (Micro-CT) The results of the eligible studies were analyzed using a soft-
2 (endodontic*) OR (“root canal”) OR 256903 ware program for meta-analysis (Stata 12.1). The change in
(“dental pulp cavity”) OR (“teeth”) OR (“tooth”) the volume of RFM with the use of supplementary methods
3 (“removal”) OR (“remnant”) OR (“remaining”) 763855 was selected as the outcome. The sample size of each group
OR (cleanliness) OR “retreatment” OR “retrieval” and the mean and standard deviation related to the volume
4 (“gutta-percha”) OR (“gutta percha”) OR (sealer) OR 200255
of RFM before and after using supplementary methods were
(paste) OR (“sealant”) OR (“filling”) OR (obturation)
5 #1 AND #2 AND #3 AND #4 123
extracted from the studies. Standardised mean difference
(SMD) was calculated for each included study. Results were
CT: Computed tomography presented in forest plots. Statistical heterogeneity between
studies was evaluated by the I2 value (43). Due to the I2 score
teeth, blinding of the outcome evaluator, measurement of the being towards 50%, the fixed-effects model was used.
outcome and selection of the reported result.
RESULTS
To make a general judgment of the risk of individual bias, each
included study was judged as having a 'low', 'moderate', and Literature search and study selection
'high' risk of bias in the case of a positive domain response The literature search resulted in a total of 239 articles from
(green), a 'high' risk of bias in the case of a negative domain PubMed, Embase, and Cochrane Library and 81 articles from
response (red), and an 'uncertain' risk of bias (yellow) when the the manual search. Following duplicate removal, 123 studies
response was not clear (42). And studies were initially judged remained. The initial selection was conducted by screening

Figure 1. A flow chart of the literature search and the selection process according to the PRISMA statement
EUR Endod J 2022; 7: 178-86 Yang et al. Effectiveness of supplementary methods for RFM 181

titles and abstracts, and 61 studies were deemed beyond the XPEF
scope of the reviewers. The corresponding full text was read Two studies evaluated the XPEF (FKG Dentaire, La Chaux-de-
when the eligibility of a given article was unclear. Twenty-six Fonds, Switzerland). Alves et al. (24) found that the XPEF sig-
studies satisfied the inclusion criteria. The details and results nificantly improved RFM removal by 69% after using a rotary
of the search strategy were shown in Figure 1. multiple-instrument system and reciprocating single-instru-
ment system. Furthermore, Aksel et al. (38) reported that ad-
Characteristics of the included studies ditional preparation with the XPEF improved the removal of
Table 2 summarises the characteristics of the reviewed stud- RFM regardless of the sealer type. Therefore, this review found
ies. Included studies evaluated the efficiency of UAI, XP-Endo convincing evidence of the efficiency of the XPEF in enhanc-
Finisher R (XPR), LAI, Gentle Wave system (GW), or SAI and ing the removal of RFM.
mechanical instruments, XP-Endo Finisher (XPEF), XPR, self-
-adjusting file (SAF), and Tornado Brush (TB) compared with GW
that of different supplementary techniques. Finally, 26 studies Two studies were found comparing the GW with other irriga-
were found suitable for the present systematic review. tion methods (28, 32). Wright et al. (32) reported that although
the efficiency of the GW (Sonendo, Inc., Laguna Hills, CA, USA)
Among the studies, the apical repreparation diameter varied was similar to that of the side-vented needle, the results were
among the experimental groups and consisted of 0.20 mm (25, better than those of the EndoVac system. However, Crozeta
27, 32, 44), 0.25 mm (20, 26, 27), 0.30 mm (38, 39, 45), 0.35 mm et al. (28) found that compared to the GW, passive ultrasonic
(37, 41), 0.40 mm(17, 19, 22, 24, 29-31, 35, 46), 0.45 mm (33), irrigation had superior results. Therefore, there is limited evi-
and 0.50 mm (21, 23, 28, 34, 40). Different filling materials were dence for the effectiveness of the GW.
applied during the first therapy and included the epoxy resin-
based sealer AH Plus (Dentsply De Trey, Konstanz, Germany) (17, LI
20, 23, 25, 26, 29, 31-36, 39-41, 44, 46, 47), a bioceramic sealer Two studies found that the additional application of a laser
(19, 22, 23, 38, 45), and Endofill sealer (Dentsply Maillefer, Bal- improves the removal of RFM in oval-shaped canals (33, 34).
laigues, Switzerland) (26, 30). Additionally, some studies used Keleş et al. (33) found that an Er:YAG laser (2,940 nm, Fidelis AT;
the continuous-wave vertical compaction technique (WVC) (17, Fotona, Ljubljana, Slovenia) was more efficient than Er: YAG-
26-28, 31-33, 36, 41, 46), some used the single-cone technique based photon-induced photoacoustic streaming (PIPS) and an
(SC) (19, 20, 22-25, 29, 30, 35, 37, 38, 44, 45), and others used Nd:YAG laser (1064 nm, Fotona, Ljubljana, Slovenia). Jiang et
cold lateral compaction (CLC) (34, 36, 39, 40). On the other hand, al. (27) examined the activation of NaOCl with Er:YAG-based
concerning the supplementary techniques, various methods PIPS (Fidelis AT, Fotona, Ljubljana, Slovenia) and found that it
were used to improve the cleaning of the root canal, including showed significantly better performance than sonic and ultra-
UAI (19, 21, 25, 26), LAI, and supplementary files (17, 24, 36-40, sonic techniques in removing RFM following the mechanical
47). Comparisons of the efficiency of several different supple- retreatment of oval root canals. However, Dönmez Özkan et
mentary methods were also made (22, 23, 27-30, 32, 35, 40, 45). al. (34) discovered that compared to conventional needle ir-
rigation, the PIPS method did not add a significant effect in
Data collection removing filling material. The largest sample size included 15
The data collected from the 26 included studies were sum- teeth. Due to the differences among studies, such as nonstan-
marised in Table 2. dard instrumentation, different irritants, and different types
of teeth, the overall performance of the irrigation methods
Risk of Bias may be affected even if the comparisons within each study re-
The risk of bias assessment for all the included studies is shown mained valid. Therefore, there was conflicting evidence in the
in Figure 2. In total, 15 studies were considered 'low' risk, while results, and not enough evidence was found for the efficiency
11 studies had moderate methodological scores. Strong evi- of LI in aiding filling removal.
dence was found to support the increased cleaning efficiency SAF
of the supplementary use of UAI, GW, LI, XPEF, XPR, and SAF. In Three studies evaluated the efficiency of the SAF (ReDent-Nova,
contrast, conflicting evidence was found to support the use of Ra'anana, Israel) (36, 39, 41). Keleş et al. (36) and Simsek et al.
sonic to improve the removal of RFM, and limited evidence was (39) reported that the additional use of the SAF enhanced the
found to support the efficiency of TB. In addition, conflicting removal of RFM after the retreatment procedure in straight and
evidence was found for the efficiency of UAI compared to XPR. curved root canals using rotary systems. Silva et al. (41) found
that both the SAF (ReDent Nova, Raanana, Israel) and the Hed-
Meta-analysis ström File (Dentsply Maillefer, Ballaigues, Switzerland) could
Ten of the included studies were suitable for meta-analysis. improve RFM removal from C-shaped canals, but the Hedström
Based on the analyses, UAI contributed significantly to increas- file significantly reduced the remaining filling material com-
ing the removal procedure [SMD (95% CI): -0.52 (-0.88 to -0.16, pared to the SAF in the total canal length (30% vs 18%). The
P=0.266)] (Fig. 3), XPR significantly improved the removal of largest sample size included 20 teeth. This review found mod-
RFM [SMD (95% CI): -0.55 (-0.89 to -0.20, P=0.136)] (Fig. 3). An erate evidence of the efficiency of the SAF in removing RFM.
additional analysis was performed to compare the efficiency
of XPR and UAI. XPR had no significant superiority in the RFM SAI
removal compared to UAI [SMD (95% CI): 0.36 (-0.12 to 0.84, Two studies (30, 31) were related to SAI. Kaloustian et al. (31)
P=0.994)] (Fig. 4). reported that compared to using instrumental preparations
TABLE 2. A summary of the methodology and the results of the studies evaluating the percentage of residual material reduction
182

Study Root morphology and sample size Retreatment instruments (Step1, Step2); Supplementary strategy; Type of Percentage of residual material
filling methods; and apical diameter of file/tip; Irrigants reduction and main findings
preparation (mm)

Silveira et al. Mesial roots of mandibular molars (Mani GPR/HyFlex NT, UAI); GP and sealer UAI; NM; 2.5% NaClO+17% EDTA PUI and UAI significantly reduced
(2018)(19) (N=40c; n=20c) 26 with SC; 0.40 the amount of filling remnants.
Da Rosa et al. Mesiobuccal and distobuccal root (PTUR, ProTaper F2 or wave one, UAI); UAI; Ultrasonic tip (15/0.02); UAI did not improve the removal
(2015)(25) canals of maxillary Molars (N=20t) GP and AH with the SC; 0.20 1% NaClO of root canal filling material.
Bernardes et al. Mandibular incisors (Reciproc/PTUR/ Hand files or Gates-Glidden, UAI; Jet Sonic and Irrisonic tip UAI improved the removal of root
(2016)(21) (N=108t; n=18t) no UAI/UAI); GP and AH;0.50 (20/0.01); 2.5% NaClO+17% EDTA filling material in all groups.
Kaloustian et al. Mesial roots of mandibular molars (TS2+Endo Ultra/TS2+Irrisafe/Reciproc+Endo UAI; File (20/0.02); 6% NaClO+17% The UAI significantly enhanced the
(2019)(26) (N=88c; n=22c) Ultra/Reciproc + Irrisafe); GP and EWT with EDTA removal of the filling material.
WVC; 0.25
Pedullà et al. Single-rooted mandibular premolars (R-Endo R3+Hyflex EDM40 #04BioRootRCS/ SNI, TB, UAI; Ultrasonic file UAI and TB were more effective than
(2019)(22) (N=72t, n=12t) GuttaFlow Bioseal+SNI/TB/UAI); GP and G1, G2 (Irrisafe 25); 3% NaClO+17% syringe irrigation in removing BR.
with the SC; 0.40 EDTA+Sterile saline
Barreto et al. Mesial roots of mandibular molars (ProTaper Retreatment instruments, UAI/NaClO, UAI/orange oil; UAI with NaClO or orange oil did not
(2016)(44) (N=30r, n=5r) Conventional/UAI or NaClO/UAI or orange oil); Ultrasonic tip; 2.5% NaClO improve filling material removal.
Reprepared with X2 and X3 ProTaper Next
Yang et al. Effectiveness of supplementary methods for RFM

instruments; GP and AH with the SC; 0.20

Alves et al. Teeth with mesial root curvatures (Mtwo /Reciproc, XPEF); GP and sealer XPEF; 2.5% NaClO 69%, XPEF significantly enhanced
(2016)(24) (N=40c, n=20c) 26 with the SC;0.40 the removal of filling material.
Campello et al. Mandibular molars (Mtwo retreatment instruments with or XPR; (2.5% NaClO+17% EDTA)/ 42%, XPR significantly improved
(2019)(37) (N=32c, n=16c) without Eucalyptol, XPR); GP and sealer (G1+Eucalyptol) removal of filling material.
26 with the SC; 0.35
Machado et al. Mandibular molars (D-RaCe system, SAF/TRUShape/XP-endo XPR; 2.5% NaClO+17% EDTA+ 38%XPR instrument enhanced
(2019)(47) (N=60 c, n=20c) Shaper, XPR); Mtwo gutta-percha cone distilled water filling material removal.
with WVC; 0.30
Aksel et al. Mesiobuccal root canals of (PTUR, XPEF); GP with the SC, AH Plus, XPEF; 2.5% NaClO XPEF improved the removal of filling
(2019)(38) mandibular 1st molars NeoMTA Plus or Endosequence BC; 0.30 material.
(N=30c, n=10c)
Volponi et al. Mandibular premolar teeth (PTN+UAI/EAI/XPEF); GP and Bio-C Sealer UAI, EAI, XPR; 17% EDTA XPR led to significantly greater filling
(2020)(45) (N=36t, n=12t) with SC; 0.30 material removal than UAI or EAI.
De-Deus et al. Mandibular incisors (M-Wire Reciproc R25, M-Wir, Reciproc R25/ Conventional needle; 2.5% The increase in apical enlargement
(2019) (11) (N=30t, n=10t) Reciproc Blue R25/XP-endo Shaper); NaClO+17% EDTA improved the removal of root fillings.
GP and AH ; 0.40
Tavares et al. Mandibular 1st premolars (Reciproc R50, XPR/R1-Clearsonic insert); XPR, R1-Clearsonic insert; 2.5% XPR and R1-Clearsonic:47.9% and
(2020)(40) (N=24t, n=12t) GP and Sealer 26 with CLC; 0.50 NaOCl 52.2% in the apical segment and
82.1% and 64.6% in the full canal.
Silva et al. Maxillary single-rooted teeth (Reciproc R25 and R40, XPEF and XPR); XPEF, XPR; 2.5% NaClO Both XPEF and XPR were equally
(2018) (17) (N=20t, n=10t) GP and AH with the continuous wave of effective in the removal of
condensation; 0.40 remaining filling material.
Simsek et al. Mandibular 1st molars (D-RaCe, SAF); SAF+GP and AH with CLC SAF; 2.5% NaClO+17% EDTA Additional use of SAF enhanced the
(2014) (39) (N=40c, n=10c) or with TT Revo-S+GP and AH with CLC or removal of filling material.
with TT; 0.30
Keleş et al. Maxillary premolars (R-Endo retreatment rotary instruments, SAF; 15% EDTA+5% NaClO Additional use of SAF significantly
(2014) (36) (N=20c, n=10c) SAF); GP and AH with CLC or VC; 0.25 improved the removal of filling
EUR Endod J 2022; 7: 178-86

material with R-Endo instruments.

TABLE 2. Cont.
Study Root morphology and sample size Retreatment instruments (Step1, Step2); Supplementary strategy; Type of Percentage of residual material
filling methods; and apical diameter of file/tip; Irrigants reduction and main findings

Silva et al. Mandibular 2nd molars (Reciproc system R25 and Mtwo rotary system, SAF or H file; 1% NaClO; The SAF file was less effective than the
(2020) (41) (N=20t, n=10t) SAF/H file); GP and sealer 26 with WVC; 0.35 H file in removing the RFM.
EUR Endod J 2022; 7: 178-86

Martins et al. Mandibular premolar Reciproc 40 +Irrisonic Tip (PUI)/RS: Reciproc PUI or Sonic agitation; 2.5% NaOCl The additional cleaning methods did
(2017)(30) (N=32c, n=8c) 40+EndoActivator /ProTaper Next with Irrisonic not improve the removal of filling
Tip/ProTaper Next with EndoActivator; GP and material significantly.
Endofill with SC;0.40
Wright et al. Mesial canals of mandibular 1st (The elementsfree downpack and a .06 tapered A 30-G side-vented needle, EndoVac, Both the side-vented needle and
(2019) (32) and 2nd molars heated plugger, .04 taper ProFile rotary files, GentleWave; 5.25% NaOCl+17% GentleWave groups were able to
(N=30t, 60c; n=10 t, 20c) a 30-G side-vented needle/ EndoVac/ EDTA, 3% NaOCl+8% EDTA remove on average more residual
GentleWave); GP and resin sealer; 0.20 obturation material than the EndoVac
group. however, the differences were
not significant.
Kaloustian et al. Mandibular molars (2Shape system/Reciproc system, MM1500 MM1500 or Eddy device; a 30 G Sonic activation with MM1500 and
(2019)(31) (N=40t, n=20t) or Eddy device); X2 GP point and AH Plus NaviTip needle; 6% NaOCL+17% Eddy significantly improved filling
sealer; 0.40 EDTA material removal.
Crozeta et al. Distal roots of mandibular molars (R50, Ultrasonic tips/XPR); GP and AH or Ultrasonic tips or XPR, R2 Ultrasonic tips should be considered
(2021)(23) (N=28c, n=14c) BC with the SC; 0.50 Flatsonic ultrasonic (size 30), a good option for endodontic
NaviTip 30-G needle; 2.5% NaOCl retreatment, especially for
bioceramic cases.
Borges et al. Mandibular incisors (Solvent, RB/PDR/WOG, XP-Endo XP-Endo Shaper, PUI, #30 H file; The XP-endo Shaper promoted
(2019) (29) (N=36t, n=12t) Shaper/PUI/H file); GP and AH Plus; a 30-gauge needle; 1% NaOCl/ significantly fewer remaining filling
0.40/0.35/0.35 (17% EDTA+2.5% NaOCl) materials in the middle and apical thirds.
Crozeta et al. Distal roots of mandibular (A Reciproc 50.05 instrument (VDW), UAI/ UAI/GentleWave; E1-Irrisonic UAI showed better performance than
(2020)(28) Molars (N=20t, n=10t) GentleWave); Gutta-percha and AHPlus sealer (20/0.01); (3% NaClO+17% EDTA)/ GentleWave.
using warm-vertical obturation; 0.50 (3% NaOCl+water rinse+8% EDTA)
Jiang et al. Single-rooted Maxillary 1st (Gates Glidden burs, ProTaper universal PIPS/Sonic/Ultrasonic Sonic, UAI, The additional use of PIPS for the
(2016)(27) premolars (N=28t, n=7t) retreatment system (D1-D3), No further/ Er: YAG laser; Sonic tip (0.2/0,02), activation of NaClO was superior to
PIPS/Sonic (EndoActivator)/Ultrasonic); Ultrasonic tip (0.2, 0.02); 3% sonic and ultrasonic techniques in
gutta-percha and AH Plus ; 0.30 NaOCl+17% EDTA removing the remaining filling materials
Keleş et al. Single-rooted Mandibular (R-Endo NiTi + 45# K-file, Er: YAG laser with Er: YAG laser/Er: YAG laser PIPS/Nd: The additional use of lasers improved
(2015)(33) canines (N=42t, n=14t) optic fiber plain tip/Er: YAG lase with a tapered YAG laser; 5% NaClO+17% EDTA the removal of filling material.
PIPS fiber tip/ Nd: YAG laser with a fiber plain
tip); GP and AH plus with VC; 0.45
Dönmez Özkan Single-rooted Mandibular PTR and conventional needle/PTR and needle Conventional needle/needle+PIPS; PIPS method did not show a
et al. (2019)(34) premolars (N=60t, n=15t) with PIPS activation/HyFlex EDM/HyFlex EDM 17% EDTA+5% NaClO significant additional effect regarding
with PIPS activation; 35# gutta-percha and AH the removal of filling material.
Plus sealer; 0.50
UAI: Ultrasonically activated agitation, GP: Gutta-percha, SC: The single-cone technique, NM: Not mentioned, EDTA: Ethylenediaminetetraacetic acid, TB: Tornado Brush, XPEF: XP-Endo Finisher, PTR: ProTaper Universal
Retreatment, XPR: XP-endo Finisher R, SAF: Self-adjusting file, EAI: EndoActivator Irrigation, PIPS: Photon-induced photoacoustic streaming, EDM: Electrical discharge machining, AH: AH Plus sealer, WVC: Continuous-wave
vertical compaction technique, CLC: Cold lateral compaction, TT: Thermoplasticized injectable techniques, VC: Vertical condensation, H file: Hedströem file, t: Teeth, c: Canal, r: Root, SNI: Syringe irrigation, EAI: EndoActivator
Yang et al. Effectiveness of supplementary methods for RFM

irrigation, RB: Reciproc Blue, PDR: ProDesign R, WOG: WaveOne Gold, PUI: Passive ultrasonic irrigation
183
184 Yang et al. Effectiveness of supplementary methods for RFM EUR Endod J 2022; 7: 178-86

a b

Figure 2. Risk of bias results of the included studies. (a) Risk of bias summary, (b) Risk of bias graph

a b

Figure 3. Forest plots of meta-analyses. (a) UAI, (b) XP-Endo finisher R

UAI: Ultrasonically activated irrigation, SMD: Standardised mean difference, CI: Confidence interval

alone, using two sonic irrigation devices, Eddy (VDW) and

MM1500 (Micro-Mega) after instrumental preparation could
significantly improve the filling material removal. However,
Martins et al. (30) found the SAI (EndoActivator) (Dentsply
Tulsa Dental Specialties, Tulsa, OK, America) was similar to UAI
(Irrisonic Tip; Helse, Santa Rosa do Viterbo, SP, Brazil) but did
not improve the removal of RFM significantly. Therefore, there
was conflicting evidence in the results.

TB
TB (Tornado France, M.I. B, Suresnes, France) can remove the
RFM by generating the hydrodynamic shear stresses from the
ultrasonic tips and centrifugal forces to brush the root canal
walls (48). Pedullà et al. (22) reported that while the TB, syringe
irrigation, and UAI achieved the same level of residual Gut- Figure 4. Forest plots of meta-analyses
taFlow Bioseal removal (GuttaFlow Bioseal, Coltene/Whale- UAI: Ultrasonically activated irrigation, SMD: Standardised mean difference, CI:
dent AG, Langenau, Germany) in the root canal, ultrasonic ac- Confidence interval
tivation and the TB were more effective than syringe irrigation
in removing BioRoot RCS (BioRoot RCS, Septodont, Saint Mau- significantly increases the removal of RFM during retreatment
r-des-Foss es, France). Since there is only one report on the use procedures, and XPR has no significant superiority over UAI. In
of TB in the removal of RFM, there is limited evidence for the addition, strong evidence was found to support the increased
efficiency of TB in removing RFM. cleaning efficiency of the supplementary use of GW, LI, XPEF,
and SAF, while conflicting evidence was found to support the
DISCUSSION use of sonic to improve the removal of RFM, and limited evi-
It is important to understand the efficiency of supplementary dence was found to support the efficiency of TB.
strategies that may potentially help improve the long-term
success of endodontic retreatment. Based on the findings of The present review focused on the studies which assess
this systematic review, the supplementary use of XPR and UAI the effectiveness of supplementary techniques for RFM
EUR Endod J 2022; 7: 178-86 Yang et al. Effectiveness of supplementary methods for RFM 185

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