ENDODONTICS

Editor:

Samuel

Seltzer

Passive step-back technique

Mahmoud Torabinejad,
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ORAL PATHOL 1994;77:3!#8-401)

The complexity and outcome of root canal therapy

generally depend on diagnostic, procedural, and prognostic difficulties encountered during treatment. Procedural difficulties can be related to obtaining adequate and profound anesthesia, effective rubber dam
application, tooth type, physiologic age of the tooth,
degree of pulpal calcification, and root canal anatomy. Histologic studies have shown that root canal
systems can be very complex, and their shapes can be
altered by age, operative procedures, decay, trauma,
periodontal disease and procedures, and passive tooth
eruption. 2-4As the degree of complexity, that is, location, size, curvature, and abnormal internal anatomy,
increases, the chance for complete removal of root
canal contents decreases, and the incidence of procedural accidents, such as ledging, canal transportation,
and perforation of the root canal system, increases.5
In addition, as the diameter of intracanal instruments
increases, their flexibility decreases. The limited flexibility and increased rigidity of large reamers and
files, the enlargement of small canals to large sizes,
and the improper use of intracanal instruments are
the main causes of procedural accidents during cleaning and shaping of the root canal systems. Several
.
chemomechanical techmques have been proposed to
clean and shape the root canal system.6-9 These techniques advocate the use of irrigation solutions during
cleaning and shaping of the root canal system and
varying degrees of coronal flaring at different stages
of root canal preparation. The amount of irrigation
Copyright
@ 1994 by Mosby-Year
Book,
0030-4220/94/$3.00
-I- 0 7/15/529&i

UNIVERSITY,

solution and the proximity of the irrigation needle to

the apex play a significant role in removing root canal
debris.1-15
Coronal flaring of root canals before apical preparation allows easier access of irrigation solution to the
apical region of the root canal system and removal of
more debris.16 In addition to providing better irrigation and debris removal, cervical flaring provides
straighter line access to the apical foramen and
reduces the chances for procedural accidents such as
debris packing, ledging, straightening of the apical
portion of the canal, perforation, and instrument
fracture.t6, l7
The step-back technique, which was first described
by Clem in 1969,1s is one of the most popular
techniques for cleaning and shaping root canals. In
this technique the canal is prepared to a small size at
the apical region, and sequentially larger files are used
to decreasing lengths. This results in a canal preparation with a small apical segment and a progressively
larger apicocoronal taper. Crown-down, step-down,
and balanced forces techniques are essentially modifications of the step-back technique, a flaring preparation with small apical opening and a coronal
enlargement. One of the major advantages of a flared
technique is the fact that it allows effective removal
of canal contents and cleaner canals. However,
studies have shown that most hand instrumentation
techniques transport the original shape of the apical
portion of the root canals.6* 20-23This might be largely
a result of the enlargement of apical region before
adequate coronal flaring or of taking small curved canals to file sizes larger than no. 25 to 30. The passive

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY

Volume 77. Number 4

Torabinejad

399

Fig. 1. Flaring accesscavity walls adjacent to the canal

orifices with a thin tapered diamond bur provide direct line
accessto the orifice of canals.

Fig. 3. Passive step-back use of files from no. 15 to no.

40 creates a mildly flared canal and removes coronal
debris.

Fig. 2. Inadequate access and coronal flare can cause

procedural accidents such as ledging and perforation.

Fig. 4. Proper use of Gates-Glidden drills provides easy

accessto the apical foramen.

step-back technique uses a combination of hand

instruments (files) and rotary instruments (GatesGlidden drills and Peesoreamers) to achieve adequate
coronal flare before apical root canal preparation.

access should unroof the pulp chamber completely

and provide the operator with a straight line to the
orifice(s) of the root canal(s). With the use of an appropriate size round bur in a high-speed handpiece,
the pulp chamber should be penetrated and unroofed
completely. After locating the canal orifice with an
endodontic explorer, flare the access cavity wall(s)
adjacent to the orifice with a thin, tapered diamond
bur (Fig. 1). Failure to create tapered wall access
cavities impedes the operators vision and his or her
control over hand- or engine-driven instruments (Fig.
2). After selection of a stable reference point and with
the diagnostic film used as a guide, place a no. 15 file
in the canal to establish an estimated working length
of root canal either with a radiograph or an electronic
apex locator.

INSTRUMENTS

No. 10 to 40 K files (Union Broach, Emigsville,

Pa.), No. 2 to 3 Gates-Glidden drills (Union Broach),
No. 2 to 3 Peesoengine reamers (Union Broach), and
high-speed round and diamond burs (Brasseler, Savannah, Ga.) were used.
CLINICAL TECHNIQUES AND RATIONALE
Step one: Access preparation. A proper and adequate accesscavity is the key to any effective cleaning and shaping procedure.24 A properly prepared

40

Torabinejad

Fig. 5. Confirmation of root canal working length with a

patency file (no. 15) prevents overextension of files after
initial flaring of the root canal.

Fig. 6. Proper use of Peeso reamers in the coronal portion

(2 to 3 mm) of the root canal can provide straighter access
for final apical preparation.

Step two: Passivestep-back hand instrumentation.

After depositing a 2.25% solution of sodium hypochlorite in the pulp chamber, place a no. 10 or 15
K-type file to the radiographic apex with a very light
one eighth to one quarter turn and push-pull strokes
to establish apical patency with little or no resistance.
With the same motion, no. 20, 25, 30, 35, and 40
K-type files are carried into the canal as far as they
can be inserted passively. After passageof these files,
the canal is irrigated with sodium hypochlorite solution. The passive step-back hand instrumentation
provides the operator with an initial insight into the
root canal anatomy, removes debris and minor obstructions from the root canal, and creates a mildly
flared canal for insertion of Gates-Glidden drills (Fig.
3).

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY

April 1994

Fig. 7. Apical root canal preparation with sequential use

of progressively larger files from the working length.

Step three: Passive use of Gates-Glidden drills. A

no. 2 Gates-Glidden drill is inserted into the mildly
flared canal to a point where it binds slightly. It is then
pulled back about 1 to 1.5 mm and the slow-speed
handpiece is activated. With an up and down motion
and slight pressure,the desired canal wall(s) is planed
and flared. A similar technique is used to plane and
flare the higher portions of the coronal region of the
root canal with the use of a no. 3 Gates-Glidden
reamer. A no. 4 Gates-Glidden reamer can be used in
large canals. The root canals should be irrigated with
2.25% sodium hypochlorite solution between uses of
the engine-driven instruments. Proper execution of
this phase of treatment provides the operator with
straighter line accessto the apical region of the canal
than an unflared canal (Fig. 4).
Step four: Confirmation of working length. Because flaring and removal of curvatures reduce the
working length, it is essential to confirm the correct
working length before apical preparation. After placing a no. 15 (Patency file) or 20 file in the canal, the
working length should be confirmed either with a radiograph or an electronic apex locator (Fig. 5). Stabholz et a1.25have shown that preflaring of root canals
makesdetection of apical constriction easier and more
predictable.
Step Jive: Passive use of Gates-Glidden drills or
Peesoreamers. A no. 2 Gates-Glidden drill or a Peeso
reamer is placed into the canal to a point where it
binds slightly. It is then pulled back about 1 to 1.5 mm
and the slow-speed handpiece is activated. With a
gentle up and down motion, the coronal portion of the
canal is shaped and flared further. With the use of a
similar technique and at a lower depth, the higher
portion of the canal (coronal 2 to 3 mm) can be flared

Torabinejad

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY

Volume 77, Number 4

with a no. 3 Gates-Glidden reamer or a Peesoreamer

(Fig. 6). Application of Peesoreamers before coronal
flaring with hand instruments and Gates-Glidden
drills and forceful application of engine-driven instruments can result in excessivehard tissue removal
and iatrogenic perforations.
Step six: Apical preparation. After flaring and determining the correct working length, a no. 20 file
should penetrate the full working length without any
resistance. The root canal is then prepared with a sequential useof progressively larger instruments placed
successivelyfurther from the working length (Fig. 7).
Narrow or curved root canals should not be enlarged
beyond the size of no. 25 or 30 files. Enlargement of
small root canals with large files results in adaption of
root canals to rigid endodontic instruments and production of apical transportation, ledging, and perforation.
The passive step-back technique provides an unforceful and gradual enlargement of root canals in an
apicalcoronal direction. In addition, it is applicable in
every canal type, easy to master, reduces procedural
accidents, and is convenient for the operator as well
as the patient.
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3. Davis SR, Brayton SM, Goldman M. The morphology of the
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4. Luks S, Bolantin L. The myth of standardized root canal instruments. NY State Dent J 1973;43:109-11.
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W.B. Saunders, 1989:300-4.
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401

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Reprint requests:
Mahmoud Torabinejad, DMD, MSD
Department of Endodontics
Loma Linda University
School of Dentistry
Loma Linda, CA 92350