Comparative investigation of two rotary nickel-titanium instruments: ProTaper versus RaCe. Part 2. Cleaning effectiveness and shaping ability in severely curved root canals of extracted teeth

Comparative Analysis of Three Nickel-Titanium Rotary Files in Severely Curved L-Shaped Root Canals: Preparation Time, Aberrations, and Fracture Rates

Background

This simulated study of 30 severely curved L-shaped root canals aimed to compare preparation time, aberrations, width measurements, and fractured files of three nickel-titanium (Ni-Ti) files, namely, ProTaper, ProTaper Next (PTN), and WaveOne (WO).

Methods

Thirty simulated L-curved root canals of resin blocks were randomly divided into three groups. The canals were prepared to a tip size of 25 using ProTaper, PTN, and WO rotary file systems. Pre- and post-operative views for each sample were captured by a professional camera at a standardized distance and position. Blue India ink was injected into the pre-operative canals, and red India ink was injected into the post-operative canals to give a clear superimposition image. Five points were assessed through the halfway of the canal to the orifice (area between the beginning of curvature and apical end point). Preparation time, aberrations, width measurements, and fractured files were recorded and analyzed.

Results

Mean preparation time was longest in ProTaper (4.89±0.68 minutes). PTN and WO were the fastest in preparing the canals (about 3 minutes). A statistically significant difference was found between WO and ProTaper & PTN and ProTaper (p=0.000), while the difference was non-significant (p > 0.05) between WO and PTN. Nine aberrations consisting of three zips, one ledge and one outer widening were related to ProTaper, while WO recorded a ledge and fractured file, but for PTN system, it verified an outer widening and ledge. Only one WO file fractured, with no deformation observed in the other instruments. No significance was recorded among the width measurements in the different levels.

Conclusion

ProTaper next achieved faster cutting than the ProTaper and WO file systems. PTN maintained the best apical termination position and produced the least canal aberration, followed by WO and ProTaper.

Minimally invasive management of vital teeth requiring root canal therapy

The present study aimed to investigate the possible use of a non-instrumentation technique including blue light irradiation for root canal cleaning. Extracted human single rooted teeth were selected. Nine different groups included distilled water, NaOCl, intra-canal heated NaOCl, and NaOCl + EDTA irrigation after either instrumentation or non-instrumentation, and a laser application group following non-instrumentation technique. The chemical assessment of the root canal dentine was evaluated using energy dispersive spectroscopy (EDS) and Fourier transform infrared (FT-IR) spectroscopy. Surface microstructural analyses were performed by using scanning electron microscopy (SEM). The antimicrobial efficacy of different preparation techniques was evaluated using microbial tests. Light application didn't change the calcium/phosphorus, carbonate/phosphate and amide I/phosphate ratios of the root canal dentin. The root canal dentin preserved its original chemistry and microstructure after light application. The instrumentation decreased the carbonate/phosphate and amide I/phosphate ratios of the root canal dentin regardless of the irrigation solution or technique (p < 0.05). The application of light could not provide antibacterial efficacy to match the NaOCl irrigation. The NaOCl irrigation both in the non-instrumentation and instrumentation groups significantly reduced the number of bacteria (p < 0.05). The use of minimally invasive root canal preparation techniques where the root canal is not instrumented and is disinfected by light followed by obturation with a hydraulic cement sealer reduced the microbial load and preserved the dentin thus may be an attractive treatment option for management of vital teeth needing root canal therapy.

Effect of Stabilized Martensite on the Long-Term Performance of Superelastic NiTi Endodontic Files

One of the most used rotary files in endodontics is NiTi files due to their superelastic properties. This property means that this instrument has extraordinary flexion that can adapt to large angles inside the tooth canals. However, these files lose their superelasticity and fracture during use. The aim of this work is to determine the cause of fracture of the endodontic rotary files. For this purpose, 30 NiTi F6 SkyTaper^® files (Komet, Germany) were used. Their chemical composition was determined by X-ray microanalysis, and their microstructure was determined by optical microscopy. Successive drillings were carried out with artificial tooth molds at 30, 45, and 70°. These tests were carried out at a temperature of 37 °C with a constant load controlled by a high sensitivity dynamometer of 5.5 N, and every five cycles were lubricated with an aqueous solution of sodium hypochlorite. The cycles to fracture were determined, and the surfaces were observed by scanning electron microscopy. Transformation (austenite to martensite) and retransformation (martensite to austenite) temperatures and enthalpies were determined by Differential Scanning Calorimeter at different endodontic cycles. The results showed an original austenitic phase with a M_s temperature of 15 °C and A_f of 7 °C. Both temperatures increase with endodontic cycling, indicating that martensite forms at higher temperatures, and the temperature must be increased with cycling to retransform it to austenite. This fact indicates the stabilization of martensite with cycling, which is confirmed by the decrease in both transformation and retransformation enthalpies. The martensite is stabilized in the structure due to defects and does not retransform. This stabilized martensite has no superelasticity and, therefore, fractures prematurely. It has been possible to observe the stabilized martensite by studying the fractography, observing that the mechanism is by fatigue. The results showed that the files fracture earlier the greater the angle applied (for the tests at 70° at 280 s, at 45° at 385 s, and at 30° at 1200 s). As the angle increases, there is an increase in mechanical stress, and, therefore, the martensite stabilizes at lower cycles. To destabilize the martensite, a heat treatment can be carried out at 500 °C for 20 min, and the files recovers all its superelasticity.

Efficacy of different irrigant activation techniques for cleaning root canal anastomosis

OBJECTIVE

This study compared in vitro the anastomosis cleaning efficacy of different irrigant activation techniques at different levels; control group non-activation (NA), passive ultrasonic irrigation (PUI) using Irrisafe, and EDDY sonic activation.

METHODS

Sixty anastomosis-containing mesial roots of mandibular molars were mounted in resin, sectioned at 2, 4, and 6 mm from the apex. Then reassembled and instrumented in a copper cube. For the irrigation technique roots were randomly divided into 3 groups (n = 20): group 1: NA, group 2: Irrisafe, group 3: EDDY. Stereomicroscopic images of anastomoses were taken after instrumentation and after irrigant activation. ImageJ program was used to calculate the percentage of anastomosis cleanliness. The percentage of cleanliness was calculated before and after final irrigation within each group and were then compared using paired t-tests. Intergroup and intragroup analyses were performed to compare between different activation techniques at the same root canal level (2, 4 and 6 mm) (intergroup) and to evaluate if each technique had different cleanliness efficacy according to the root canal level (intragroup) using one-way analysis of variance and post hoc tests (p < 0.05).

RESULTS

All three irrigation techniques significantly improved anastomosis cleanliness (p < 0.001). Both activation techniques were significantly better than the control group at all levels. Intergroup comparison revealed that EDDY significantly achieved the best overall anastomosis cleanliness. The difference between EDDY and Irrisafe was significant in favor to EDDY at 2 mm and insignificant at 4 and 6 mm. The intragroup comparison showed that improvement in anastomosis cleanliness (i2-i1) in the needle irrigation without activation group (NA) was significantly higher in the apical 2 mm level compared to the 4 & 6 levels. While the difference in anastomosis cleanliness improvement (i2-i1) between levels in both Irrisafe and EDDY groups was insignificant.

CONCLUSIONS

Irrigant activation improves anastomosis cleanliness. EDDY was the most efficient in cleaning anastomoses located in the critical apical part of the root canal.

CLINICAL RELEVANCE

Cleaning and disinfection of the root canal system followed by apical and coronal sealing is the key for healing or prevention of apical periodontitis. Remnants of debris and microorganisms retained within the anastomoses (isthmuses), or other root canal irregularities may lead to persistent apical periodontitis. Proper irrigation and activation are essential for cleaning root canal anastomoses.

Histological Investigation of the Cleaning Effectiveness of Different Biomechanic Processes of Isthmus in Lower Molars

Objectives This study aimed to evaluate the efficacy of different instruments (Hyflex, ROTATE, and hand files) and irrigation methods (EndoUltra, EndoActivator, and side-perforated syringe) in the mesial root canal of a mandibular first molar with isthmuses.

Materials and Methods Sixty-three mandibular molar teeth with isthmus were selected using cone beam computed tomography (CBCT) images. The root canals were instrumented with Hyflex, ROTATE, or hand files (21 of each) and three of each as control group and the specimens were embedded in silicone blocks. Final irrigation was performed with the perforated syringe or ultrasonic (EndoUltra) or sonic irrigation (EndoActivator). All canals were irrigated using 5.25% NaOCl solution (15 mL). Then, the roots were stained with hematoxylin–eosin, and specimens were sliced for histologic evaluation. The isthmus regions (2.7, 3, 4.7, and 5 mm from the apex) were analyzed, and the percentage of debris was calculated.

Statistical Analysis All data were statistically analyzed using one-way analysis of variance and Tukey's tests.

Results Both Hyflex and ROTATE groups showed less debris compared with the hand instrument group (P < 0.05). When irrigation methods were compared, EndoUltra showed the least, followed by EndoActivator and perforated needle irrigation having the maximum debris (p < 0.05). When sections were compared, the maximum debris was found in the apical section and the least in the coronal section (p < 0.05).

Conclusion Although none of the methods cleaned the isthmus completely, nickel–titanium (NiTi) systems and ultrasonic and sonic systems removed more debris than the side-perforated needle syringe irrigation.

Evaluation of the Canal Transportation Following Glide Path Preparation with Different Rotary Systems: A Comparative Study

Objectives. Ideal root canal shaping might be more challenging particularly in cases with severely curved canals or complex anatomical variations. Glide path preparation is suggested as a critical step to achieve ideal canal preparation. The present study is aimed at evaluating transportation at different levels of the canal following glide path preparation by five different path finders. Materials and Methods. The study was conducted on 100 S-shaped canal simulator blocks. Glide path was prepared in five groups including (1) Scout RaCe (#10 and #15, 0.02), (2) One G (#14, 0.03), (3) PathFile (#13 and #16, 0.02), (4) GPS (#15, 0.03), and (5) K file (#15, 0.02) (Control group). The first four groups were NiTi rotary instruments, while the last group was a stainless steel hand file. The aforementioned files were used after canal negotiation by a #10 stainless steel hand file. Before- and after-preparation photos were taken and were superimposed in Adobe PhotoShop CC 2019. Transportation measurements were conducted in Digimizer. Absolute canal transportation was calculated at 10 cross-sections. Intergroup and intragroup data analysis were conducted using one-way and repeated measures ANOVA tests, respectively, in SPSS 26.0. The significance level was set to 0.05. Results. Although K file led to significantly more transportation in the apical and middle thirds ( $p<0.001$ ), rotary groups were not statistically different. In the coronal third, K files led to significantly more transportation compared to Scout RaCe and PathFile ( $p<0.05$ ). Conclusion. Within the limitations of the present study, regardless of the recruited rotary system, glide path preparation using NiTi rotary instruments leads to less canal transportation compared to stainless steel hand files.

Comparative Assessment of the Shaping Ability of Reciproc Blue, WaveOne Gold, and ProTaper Gold in Simulated Root Canals

Maintaining the original trajectory of the root canal is a major challenge in endodontic therapy, especially in narrow and curved root canals. The present study aims to assess the shaping capacity of three endodontic systems made of different nickel−titanium alloys on simulated curved root canals. Thirty-six endodontic resin blocks (Ref. V040245, VDW) divided into three groups, each of twelve blocks (n = 12), were shaped, photographed, and analyzed: Group 1-Protaper Gold (PTG) (Dentsply Maillefer, Ballaigues, Switzerland) F2 25/08; Group 2-Reciproc Blue (RB), RB 25/08 (VDW, Munich, Germany); Group 3-WaveOne Gold (WOG) (Dentsply Maillefer), WOG 25/07. Each block was standardized and photographed before and after shaping in the same position, with the foramen oriented to the left. Post-shaping images were superimposed onto the initial ones. Thirteen measurement points were used for evaluation, spaced with 1 mm distance from one another, from level 0, apical foramen, to level 12, coronal orifice. The amount of removed resin from inner (X1) and outer (X2) walls, the direction of transportation (X1 − X2), and the centering ability (X1 − X2)/Y were measured, calculated, and comparatively analyzed. Statistical differences (p < 0.05) were observed between the shaping capacity of the considered systems in the middle and coronal thirds. PTG had a better centering ability than WOG and RB in the coronal third, while RB was more centered in the middle third in comparison to both WOG and PTG. In the apical third, the centering capacity of WOG was higher, without being statistically significant. WOG 25/07 and PTG 25/08 tend to cut more on the inner wall of the root canals, and RB 25/08 on the external one.

Comparison of Cleaning Efficiency of Root Canal Using Different Rotary NiTi Instrumentation System: A Scanning Electron Microscopic Study

Background: To ensure that endodontic treatment is as effective as possible, it is important to remove any smear layer that forms as part of the instrumentation procedure. This layer might reduce the overall effectiveness of endodontic therapy.

Aim of the study: For this research, two distinct types of rotary NiTi files were compared: WaveOne Gold (WOG) (Dentsply Maillefer, Ballaigues, Switzerland) and F360 (Komet Brasseler GmbH & Co., Lemgo, Germany) for its capacity to eliminate trash and the smear layer.

Materials and methods: Two groups (n=20 each) of 40 mandibular second premolar teeth were employed in this investigation, with each group receiving a random allocation of teeth. The F360 system and the WaveOne Gold system are two sets of instruments. The samples were irrigated with a mixture of sodium hypochlorite (NaOCl) (5.25%) and citric acid (40%). Finally, all samples in the centre of the coronal, middle, and apical thirds were examined by scanning electron microscopy (SEM). Mann-Whitney U tests were used to analyse the data.

Results: F360 instrument showed a statistically significant difference for smear layer removal among all thirds of the root canal whereas WOG resulted in a significant difference when the apical third was compared to the middle and coronal third. Significant differences were found in the middle and apical third in terms of smear layer removal between the two groups.

Both F360 and WOG instruments showed statistically significant differences for debris removal among all thirds of the root canal. No significant differences were found in the coronal, middle, and apical third in terms of debris removal between the two groups.

Conclusion: WOG resulted in cleaner canals compared to the F360 file system at coronal, middle, and apical third.

New heat-treated vs electropolished nickel-titanium instruments used in root canal treatment: Influence of autoclave sterilization on surface roughness

Nickel-titanium (NiTi) instruments used to treat root canal infections are affected by autoclave sterilization in various ways. The aim of this study was to compare the effect of autoclave sterilization on two NiTi rotary instruments that undergo different manufacturing treatments: The electro-polished Race and the heat-treated Race Evo, using scanning electron microscope analysis. In this in-vitro study, Race and Race-Evo instruments were subjected to a number of autoclaving cycles (0, 1, 3, 5, and 10). Scanning electron microscopy images were obtained at 3 mm from the tip of the file at 450x and 1000x magnifications. Surface roughness parameters were measured using ImageJ software. The results showed that autoclave sterilization caused a significant decrease in conventional NiTi Race surface roughness. While in Race Evo, surface roughness increased following the first autoclaving cycle. After 10 autoclaving cycles, surface roughness significantly decreased for both Race and Race Evo files.

Evolution and development: engine-driven endodontic rotary nickel-titanium instruments

Various engine-driven NiTi endodontic files have been indispensable and efficient tools in cleaning and shaping of root canals for practitioners. In this review, we introduce the relative terms and conceptions of NiTi file, including crystal phase composition, the design of the cutting part, types of separation. This review also analysis the main improvement and evolution of different generations of engine-driven nickel-titanium instruments in the past 20 years in the geometric design, manufacturing surface treatment such as electropolishing, thermal treatment, metallurgy. And the variety of motion modes of NiTi files to improve resistance to torsional failure were also discussed. Continuous advancements by the designers, provide better balance between shaping efficiency and resistance to of NiTi systems. In clinical practice an appropriate system should be selected based on the anatomy of the root canal, instrument characteristics, and operators' experience.

Effect of Autoclaving Cycles on the Cyclic Fatigue Resistance of Race and Race Evo Nickel-Titanium Endodontic Rotary Files: An In Vitro Study

Objective: The aim of this study was to evaluate the influence of autoclave sterilization on the resistance to cyclic fatigue of two nickel-titanium (NiTi) endodontic files of identical design and taper, but with different NiTi alloy treatments: the newly introduced heat-treated Race Evo and the electropolished Race files. Materials and methods: Fifteen Race (25/0.06) files and fifteen Race Evo (25/0.06) files (n = 30 in total) were randomly assigned to five sub-groups each consisting of three files of the same NiTi alloy treatment. One group served as a control with files unautoclaved. The four remaining groups were sterilized in a steam sterilizer for 1, 3, 5, and 10 autoclave cycles, respectively. Files then underwent cyclic fatigue testing in a simulated metal canal block. A scanning electron microscope was used to inspect the surface of the fractured instruments. Statistical analysis was conducted using independent t-test and multi-factorial analysis of variance with significance set at a p value of ≤0.05. Results: Both Race Evo and Race files showed no significant difference between the different autoclaving cycles in terms of the number of cycles to fracture (p = 0.232 and p = 0.359). Despite rotating at a higher speed, the number of cycles to fracture of heat-treated Race Evo files was significantly higher than that of Race files (p ≤ 0.0001). Conclusion: Autoclave sterilization has no significant effect on the resistance to cyclic fatigue of heat-treated Race Evo or electropolished Race files. However, Race Evo files showed superior resistance to cyclic fatigue irrespective of autoclaving cycles.

Influence of Apical Preparation Size on Effective Conventional Irrigation in the Apical Third: A Scanning Electron Microscopic Study

Objective

This study aimed to investigate the relationship between final apical preparation size and smear layer removal in the apical third using conventional irrigation in mandibular bicuspids.

Methods

A total of 66 extracted human mandibular bicuspids with comparable root canal morphology were equally divided into five experimental groups and a control group (n=11). Based on their experimental group, samples were instrumented up to size 25, 30, 35, 40, or 45 with 0.04 taper using 2.5% sodium hypochlorite (NaOCl) as the irrigant. Final irrigation was performed with 17% EDTA followed by 2.5% NaOCl. The control group was instrumented up to size 45/.04, and was irrigated with distilled water. Samples were sectioned buc-colingually, and they were qualitatively evaluated under scanning electron microscope for efficacy in smear layer removal. The Kruskal-Wallis and Mann-Whitney U tests were employed for statistical analysis.

Results

Statistical analysis revealed comparable removal of smear layer in the coronal and middle thirds of all experimental samples regardless of grouping. When using file size larger than 35, removal of smear layer in the apical third significantly improved (p<0.05). No significant difference was observed between 40/.04 and 45/.04.

Conclusion

Under the conditions of this study, using conventional irrigation, apical enlargement more than size 35/.04 is essential to enhance removal of smear layer at the apical third.

A comparative study of root canal shaping using protaper universal and protaper next rotary files in preclinical dental education

Background

Dentistry has undergone an evolution in endodontics practice caused by the advancement of rotary techniques for root canal preparation and their subsequent incorporation into the teaching of dentistry undergraduates. This research aimed to evaluate the shaping ability of third-year dental students as their first experience in rotary instrumentation using ProTaper Universal (PTU) and ProTaper Next (PTN) (Dentsply Maillefer) rotary instruments in simulated curved canals.

Methods

Forty students instrumented 200 simulated canals with a 40° curvature in resin blocks according to the manufacturer’s instructions with PTU and 39 students and 195 canals with PTN files. The canals were prepared at a speed of 300 rpm using a 16:1 reduction hand-piece powered by an electric motor (Xsmart; Dentsply Maillefer). The final apical preparation was set to F2 for the PTU and X2 for the PTN group. The change in canal curvature was evaluated based on Schneider technique using the AutoCAD 2007 software on post-digital photographs. The incidence of instrument fracture and deformation, the incidence of ledge, the change in working length (WL), and the working time were noted. The data were analyzed with Student’s t-test and Chi-Square test at a significance level of 0.05 using SPSS.

Results

PTN maintained the original canal curvature better, resulting in fewer fractures and ledges, and shaped the canals faster than the PTU (P < 0.05). The mean curves of the resin canals after the instrumentation for the PTU and PTN groups were 24.03° ± 3.14° and 25.64° ± 2.72°, respectively. Thirty-three (17.4%) PTU and 18 (9.3%) PTN files fractured (p < 0.05). Nine (4.5%) PTU and 2 (2.6%) PTN deformed (p > 0.05). The change in WL after instrumentation was 0.97 mm ± 0.95 mm in PTU and 0.96 mm ± 0.80 mm in PTN (p < 0.05). The mean times were 627 s ± 18 s for PTU and 379 s ± 18 s for PTN (p < 0.000).

Discussion

PTN can be recommended in severely curved root canals in terms of maintenance of the original canal curvature, superior instrument fracture and fewer ledges. Even if training before preparation provides an acceptable level of canal shaping for preclinical students, the use of NiTi rotary instruments should be included in the undergraduate dental curriculum, contributing to an increase in the quality of root canal shaping and, consequently, to an improvement of the clinical experience of students.

Comparison between the Effectiveness of Rotary and Manual Instrumentation in Primary Teeth: A Systematic Review

Aim

To develop a scientifically current and evidence based protocol on the efficacy of rotary and hand root canal instrumentation in primary teeth.

Materials and methods

Previous randomized control trials were used for the current review. Hand search and online search engines of PUBMED and Google Scholar were used to search English language articles with human subjects published up to December 2016.

Results

After screening of the abstracts and articles, based on the inclusion and exclusion criteria a total of 13 articles were included in the systematic review.

Conclusion

Rotary instrumentation shows equivalent cleaning efficiency than hand files depending on the system of instrumentation and techniques used. However, use of rotary in primary teeth leads to improved shaping of canals providing better quality of treatment in less time.

How to cite this article

Panchal V, Jeevanandan G, et al. Comparison between the Effectiveness of Rotary and Manual Instrumentation in Primary Teeth: A Systematic Review. Int J Clin Pediatr Dent 2019;12(4):340–346.

Nickel-titanium instruments in endodontics: a concise review of the state of the art

The introduction of automated instrumentation in endodontics represented a major advance in progress for this specialty, with improvements in the quality and predictability of root canal preparation and a significant reduction in procedural errors. In recent years, endodontic instruments have undergone a series of changes brought about by modifications in design, surface treatments, and thermal treatments. In addition, new movements have also been incorporated to offer greater safety and efficiency, optimizing the properties of the NiTi alloy, especially through eccentric rotary motion. An understanding of the mechanical properties of these new NiTi instruments and their effect on the clinical performance of root canal preparation is essential if dental practitioners are to select the instruments that provide optimal clinical outcomes, especially in curved or flattened canals. The objective of this literature review is to present and discuss the characteristics of the NiTi alloys used in the major instrumentation systems available in the market, as well as the influence of the metallurgical and mechanical properties of NiTi instruments and the movements that drive them, to enable more accurate and predictable planning of root canal preparation.

Nickel-Titanium Rotary Instruments: Development of the Single-File Systems

Over the past two decades, the nickel-titanium (NiTi) rotary instruments have highly improved the quality of the cleaning and shaping of the root canals. The superelasticity and shape memory of these instruments reduce the possibility of the canal transportation along with saving the time for both the patients and the clinicians. Several commercial types of these instruments, produced by different manufacturers, have currently become available by modifying the characteristics of the wonder NiTi alloy and also the cross-sectional shapes, cutting edges, tapering and numbers and distances of the flutes of the instruments. Up to this date, five generations for NiTi rotary instruments have been described according to the time of introduction, properties, and method of application. The aim of this article is to review the evolution of these five generations of NiTi rotary instruments since their inception.

Multidimensional Analysis of Curved Root Canal Preparation Using Continuous or Reciprocating Nickel-titanium Instruments

Objective:

To evaluate transportation (T) and centering ability (CA) of root canal preparations using continuous or reciprocating nickel-titanium endodontic files.

Materials and Methods:

Ninety-six mesiobuccal root canals of mandibular first and second molars were randomly divided into 6 groups (n=16) according to the rotary file used: 1. ProTaper Next; 2. ProTaper Gold; 3. Mtwo; 4. BioRaCe; 5. WaveOne Gold; 6. Reciproc. Root canals were prepared according to manufacturer’s instructions. Cone beam computed tomography scans were obtained before and after root canal preparation. Measurements were made at six different reference points: 2, 3 and 4 mm from the apex and 2, 3 and 4 mm below furcation in different directions.

Results:

The greatest Mesiodistal (MD) Transportation (T) was found for Reciproc files (p<0.05), and the greatest buccolingual (BL) T, for Reciproc, ProTaper Gold and ProTaper Next files (p<0.05). The greatest Mesiodistal (MD) Centering Ability (CA) was found for BioRaCe files (p<0.05), and the greatest Buccolingual (BL) CA, for BioRaCe and Mtwo files (p<0.05).

Conclusion:

All systems produced root canal transportation. No file system achieved perfect CA of root preparation. Reciproc files had the greatest MD T and BL T. BioRaCe files had the greatest MD CA, whereas BL CA was similar for BioRaCe and Mtwo files.

Preparation Prerequisites for Effective Irrigation of Apical Root Canal: A Critical Review

Background

It is well recognized that disinfection of the complex root canal system at the apical root canal remains the most critical therapeutic measure to treat apical periodontitis.

Material and Methods

Observational and experimental data in relation to the anatomy of the apical root canal in different tooth types and the cross sectional diameters of the apical part of the most commonly used hand and rotary files are critically reviewed.

Results

The present data analysis confirm that the challenging issue of antibacterial efficacy of modern preparation protocols in non-surgical endodontics requires more attention to apical root canal irrigation as a balance between safety and effectiveness. Ex vivo investigations clearly indicate that a specific design of the chemo-mechanical preparation is needed at the onset of RCT, more particularly in infected teeth. Design should be based on specific anatomical parameters, and must determine the appropriate size and taper of preparation as pre-requirements for effective and safe apical irrigation.

Conclusions

The optimal irrigation protocols might be designed on the basis of technical specifications of the preparations procedures, such as the penetration depth, the type of the needle, the required time for continuous irrigant flow, the concentration of NaOCl, and the activation parameters.

Key words:Endodontics, root canal treatment, instrumentation, irrigation, apical root canal.

Cleanliness of Canal Walls following Gutta-Percha Removal with Hand Files, RaCe and RaCe plus XP-Endo Finisher Instruments: A Photographic in Vitro Analysis

INTRODUCTION

Gutta-percha must be removed from the root canal space during retreatment to ensure a more favorable outcome. The aim of this study was to compare the efficacy of hand instruments, RaCe and RaCe plus XP-endo finisher instruments in removal of gutta-percha from root canal walls during retreatment.

METHODS AND MATERIALS

Thirty single-rooted premolars were prepared, obturated, and divided into three groups according to retreatment method; in group 1, retreatment was carried out by hand instruments, while in groups 2 and 3 retreatment was done using RaCe rotary files alone or accompanied by XP-endo finisher instruments, respectively. After retreatment, teeth were sectioned longitudinally and photographic images were taken. The amount of remaining gutta-percha in coronal, middle and apical thirds was quantified using Image J software. The two-way ANOVA and post hoc Tukey's tests were used to analyze data. The level of significance was set at 0.05.

RESULTS

RaCe cleaned the apical third significantly better than hand instrumentation. In the coronal third, RaCe+XP-endo finisher was more effective than RaCe. RaCe+XP-endo finisher was more effective than hand instrumentation in the entire root canal. The amount of remaining gutta-percha was the least in the apical part and increased toward the coronal part with the use of XP-endo finisher (P<0.05).

CONCLUSION

Rotary instrumentation was more effective in removing gutta-percha from the canal walls. Furthermore, use of XP-endo finisher file resulted in cleaner canal walls and was more effective in removing gutta-percha from the coronal toward the apical part of the canal.

Wear of the Primary WaveOne single file when shaping vestibular root canals of first maxillary molar

Background

It is very important for a clinician to know the increased wear of mechanized files when establishing endodontic therapy. The aim of this study was to check the wear of the Primary WaveOne file upon shaping two, four and six maxillary molar vestibular canals.

Material and Methods

The deterioration of 40 files, divided into four groups, was evaluated microscopically: group 1, control (unused); group 2, two canals; group 3, four canals; and group 4, six canals. After instrumentation, the files were embedded in resin and sectioned at their apical third into three equal parts. To analyze the wear of edges in the different sections, AutoCAD software was used and analysis of variance (ANOVA) was then performed to compare the mean rake angles.

Results

The files with two and four uses showed slight wear, whereas those with six applications showed significant wear (p<0.05).

Conclusions

Primary WaveOne files can be used in up to four root canals without their edges losing effectiveness.

Key words:Files wear, reciprocating motion, shaping capacity, WaveOne.

Cleaning Effectiveness of a Reciprocating Single-file and a Conventional Rotary Instrumentation System

Objective:

To compare cleaning effectiveness by histological analysis of a reciprocating single-file system with ProTaper rotary instruments during the preparation of curved root canals in extracted teeth.

Methods:

A total of 40 root canals with curvatures ranging between 20 - 40 degrees were divided into two groups of 20 canals. Canals were prepared to the following apical sizes: Reciproc size 25 (n=20); ProTaper: F2 (n=20). The normal distribution of data was tested by the Kolmogorov-Smirnov test and the values obtained for the test (Mann-Whitney U test, P < .05) were statistically analyzed using the GraphPad InStat for the Mac OS software (GraphPad Software, La Jolla, CA, USA).

Results:

There were no significant differences in remaining debris (P > .05) between the two groups.

Conclusion:

The application of reciprocating motion during instrumentation did not result in increased debris when compared with continuous rotation motion, even in the apical part of curved canals. Both instruments resulted in debris in the canal lumen, irrespective of the movement kinematics applied.

Comparison of the shaping ability of RaCe, FlexMaster, and ProFile nickel-titanium instruments in severely curved root canals

Background

This in vitro study compared the shaping ability of RaCe, FlexMaster, and ProFile rotary nickel-titanium instruments in severely curved root canals of extracted teeth.

Material and Methods

Sixty maxillary molars with curvatures ranging from 25° to 65° were embedded in a muffle system and portioned into five horizontal sections (thickness 1.2 mm), starting from the apex. Canals were divided into three groups (n = 20, each) and were prepared with RaCe, FlexMaster, or ProFile rotary nickel-titanium instruments and the TriAuto ZX handpiece using a crown-down preparation technique. We evaluated the difference between pre- and postoperative root canal cross-sections, loss of working length, instrument failure, and preparation time. The root canal area before and after the intervention was determined using an area-measuring software. The data were analyzed statistically using a one-way ANOVA followed by a Kruskal-Wallis multiple-comparison Z-value test.

Results

Specimens treated with FlexMaster showed the greatest change from preoperative cross-sections, followed by RaCe and ProFile. The cross-sectional changes induced by RaCe and FlexMaster preparation differed significantly from those produced by ProFile. Loss of working length, instrument failure, and preparation time did not differ significantly between the groups.

Conclusions

Root canal preparation with the three instruments did not lead to any significant alteration of the original root anatomy or working length. Thus, we conclude that RaCe, FlexMaster, and ProFile instruments are of comparable efficiency and usefulness in the preparation of severely curved root canals.

Key words:Endodontics, root canal preparation, rotary, extracted teeth, nickel-titanium.

Comparing the Coronal Flaring Efficacy of Five Different Instruments Using Cone-Beam Computed Tomography

INTRODUCTION

Fearless removal of tooth structure during canal preparation and shaping has negative effects on the prognosis of treatment. On the other hand, sufficient pre-enlargement facilitates exact measurement of the apical size. The present in vitro study aimed to compare the efficacy of Gates-Glidden drills, K3, ProTaper, FlexMaster and RaCe instruments in dentin removal during coronal flaring using cone-beam computed tomography (CBCT).

METHODS AND MATERIALS

A total of 40 mandibular molars were selected and the coronal areas of their mesiobuccal and mesiolingual root canals were randomly prepared with either mentioned instruments. Pre- and post-instrumentation CBCT images were taken and the thickness of canal walls was measured in 1.5- and 3-mm distances from the furcation area. Data were analyzed using the one-way ANOVA. Tukey's post hoc tests were used for two-by-two comparisons.

RESULTS

At 1.5-mm distance, there was no significant difference between different instruments. However, at 3-mm distances, Gates-Glidden drills removed significantly more dentin compared to FlexMaster files (mean=0.18 mm) (P<0.02); however, two-by-two comparisons did not reveal any significant differences between the other groups.

CONCLUSION

All tested instruments can be effectively used in clinical settings for coronal pre-enlargement.

A Comparative SEM Investigation of Smear Layer Remaining on Dentinal Walls by Three Rotary NiTi Files with Different Cross Sectional Designs in Moderately Curved Canals

OBJECTIVE

The objective of this study was to compare the smear layer formed on root canal walls during canal preparation of extracted human teeth by Twisted, Mtwo, and ProTaper rotary nickel titanium instruments.

MATERIALS AND METHODS

Sixty single rooted human premolar teeth with root curvature <25(0) were selected and randomly divided into three Groups (n= 20 teeth per Group). Three types of rotary nickel titanium instruments were used, Twisted (SybronEndo, Orange, CA, USA), Mtwo (VDW, Munich, Germany) and ProTaper (Dentsply Maillefer, Ballaigues, Switzerland) according to manufacturer's instructions to instrument the root canals. Irrigation for all groups was performed after each instrument change with 3ml of 3% sodium hypochlorite followed by Glyde (File Prep, Dentsply, Maillefer, Ballaigues, Switzerland) as chelator paste and lubricant. Three different areas (coronal, middle and apical thirds) of the root canal were evaluated using scanning electron microscopy (SEM). The canal wall of each sample was assessed and compared using a predefined scale for the presence or absence of smear layer. Data were analysed statistically using ANOVA and Tukey HSD test Results: All three groups showed statistically significant more smear layer in the apical thirds of the canal as compared to the coronal and middle thirds (p<0.001). Mtwo rotary file system produced significantly less smear layer (p<0.001) compared to Twisted and ProTaper rotary instruments in the apical portion. Twisted Files resulted in less smear layer formation in the apical thirds of the canal compared to ProTaper rotary instruments but were statistically insignificant.

CONCLUSION

Completely clean root canals were not found after instrumentation with any of the three instruments. Under the confines of this study Mtwo instruments produced significantly cleaner dentin wall surfaces throughout the canal length in comparison to Twisted and ProTaper rotary files. Twisted Files proved to be comparable to ProTaper rotary instruments with respect to canal cleanliness in the apical thirds of the root canal.

Shaping ability of ProTaper Universal, WaveOne and ProTaper Next in simulated L-shaped and S-shaped root canals

Background

The purpose of this study was to compare the shaping ability of the ProTaper Universal (PTU; Dentsply Maillefer, Ballaigues, Switzerland), WaveOne (WO; Dentsply Maillefer) and ProTaper Next (PTN; Dentsply Maillefer) in simulated L-shaped and S-shaped root canals respectively.

Methods

30 simulated L-shaped and 30 simulated S-shaped root canals in resin blocks were employed and randomly divided into 3 groups (n = 10), respectively. The canals were prepared to a tip size 25 using PTU, WO or PTN: PTU F2 (taper 0.08 over the first 3 mm from apical tip), WO Primary (taper 0.08 over the first 3 mm from apical tip), and PTN X2 (taper 0.06 over the first 3 mm from apical tip). Photos of the simulated root canals were taken pre- and postinstrumentation. The 2 layers were superimposed after a series of image processing and 10 points were selected from apical constriction with 1 mm interval. And then the central axis transportation and straightened curvature were measured with software of image analysis.

Results

In simulated L-shaped root canals, PTU and PTN caused less transportation than WO at curved section (P < 0.05), and PTN caused the least transportation at apical constriction (P < 0.05). Moreover, PTN maintained the canal curvature best among the 3 groups (P < 0.05). But PTN produced more transportation at straight section compared with PTU and WO (P < 0.05). In simulated S-shaped root canals, PTN preserved the coronal curvature best (P < 0.05), but there was no significant difference in apical curvature since all the files straightened the curvature obviously.

Conclusions

PTN showed a better shaping ability than PTU and WO at the curved section of root canals, and PTN maintained the best apical constriction. But all the files had a tendency to straighten the apical curvature in multi-curved canals.

Modifications in Canal Anatomy of Curved Canals of Mandibular First Molars by two Glide Path Instruments using CBCT

BACKGROUND

The creation of glide path reduces the risk of instrument breakage. Glide path is created before using NiTi rotary instrumentation Aim: This study compared the changes in the root canal anatomy after creation of glide path using Path Files (PF) and V Glide Path 2 (VGP2) using Cone Beam Computed Tomography (CBCT).

MATERIALS AND METHODS

Hundred extracted mandibular first molars with curved mesial roots, curvature angles ranging within 20-30 degrees were assigned into two groups (n = 50 each). Glide path was prepared using PF (Group I) and VGP2 (Group II). CBCT images were obtained before and after instrumentation. The technical outcomes were compared at 0, 1, 2, 3, 5 and 7mm intervals. The data was analyzed using t-test and Chi-square test.

RESULT

There was a statistical difference between the root canal curvatures and working time between the two groups (p < 0.05). Canals transported towards the distal side in Group II but there was a slight mesial transportation in Group I at 0mm. Group I exhibited a better centric ability except at 1mm interval (p > 0.05). The changes in the volume were statistically significant only at 2mm interval (p < 0.05). The difference in the cross sectional area was not statistically significant at any interval (p > 0.05).

CONCLUSION

Within the limits of this study the rotary Nickel Titanium Path Files appeared to be suitable instruments for safe and easy creation of glide path.

Comparison of Cleaning Efficacy and Instrumentation Time in Primary Molars: Mtwo Rotary Instruments vs. Hand K-Files

INTRODUCTION

Pulpectomy is the preferred treatment for restorable primary teeth with symptomatic irreversible pulpitis or periradicular lesion. Considering the rather new application of rotary files for pulpectomy of primary teeth, the aim of this study was to compare the cleaning efficacy and instrumentation time of hand K-files and Mtwo rotary system for preparation of human primary molars.

METHODS AND MATERIALS

This experimental study was conducted on 100 extracted primary maxillary and mandibular intact molars with no resorption. Access cavities were prepared and India ink was injected into the root canal on a vibrator using an insulin syringe. Canals were then divided into 5 groups (n=20): in group I, canals were instrumented using K-files up to #25 for mesial and buccal canals and #30 for palatal and distal canals. In group II, canals were prepared using Mtwo rotary files (15/0.05, 20/0.06 and 25/0.06 for mesial and buccal canals and 15/0.05, 20/0.06, 25/0.06 and finally 30/0.05 for distal and palatal canals). In group III, root canals were only irrigated with saline. Groups IV and V were the positive and negative control groups, respectively. The time required for cleaning and preparation of the canals for each of the specimens in groups I, II and III was recorded.

RESULTS

The mean score of cleanliness of Mtwo was not significantly different from K-file group (P>0.05). However the mean instrumentation time in Mtwo group was significantly shorter (P<0.001).

CONCLUSION

Although there were no differences regarding the cleaning efficacy of either system, Mtwo rotary files were far more time efficient.

Scanning electron microscopy comparison of the cleaning efficacy of a root canal system by Nd:YAG laser and rotary instruments

This study evaluated the cleaning efficacy of a root canal system by Nd:YAG laser and rotary instruments. Sixty single-rooted human teeth were divided into four experimental groups (n=15). In the first group the teeth were prepared with a step-back technique using conventional K-files. In the second and third groups, tooth preparation was carried out using Nd:YAG laser and rotary NiTi instruments, respectively. Teeth in the fourth group were prepared by combined laser and rotary methods. The smear layer remaining on canal walls was then assessed by scanning electron microscopy in the coronal, middle, and apical portions. The comparison of smear layer removal efficacy between groups was carried out by Kruskal-Wallis and Mann-Whitney U tests. The mean grades of smear layer removal in rotary-laser, rotary, laser and step-back techniques were 1.34 ± 0.18, 2.2 ± 0.28, 1.91 ± 0.25, and 2.42 ± 0.19, respectively. On the whole, differences between rotary-laser and rotary groups, step-back, and the three other techniques (rotary, laser, and rotary-laser) were significant at p=0.034. Based on the findings of this study, the cleaning efficacy of rotary, laser, and rotary-laser techniques were better than the step-back technique and the combined laser and rotary technique was the most efficient method.

SEM analysis of defects and wear on Ni-Ti rotary instruments

SEM analysis of endodontic instruments from a Ni-Ti rotary system was assessed, before and after using them, considering their defects and deformations. Twenty Twisted File®, BioRąCe®, Mtwo®, and EndoWave® instruments were micrographed at 190× magnification. The files were washed and micrographed again to view alterations as to the presence or absence of irregular edges, grooves, microcavities, and scraping. Simulated root canal preparations were performed using these instruments. The instruments were cleaned and received a microscopic analysis after being used five times. After analysis tests were tested using Fisher's exact test and Kappa to evaluate the concordance among examiners. There was a statistically significant difference with respect to deformations between Twisted File® and other instruments (p < 0.05). There was no statistically significant difference in strains between the other groups (p > 0.05). All Twisted File® instruments showed the same defects; however damage were lower than those found in BioRace® and Mtwo®. The Endowave® did not show the same defects. In accordance with the data we conclude that the presence of defects was higher in Twisted File® instruments as the instruments and BioRace® Mtwo® brand, the defect rate was smaller and Endowave® instruments had no defects. Regarding the presence of wear after five uses among the groups all instruments showed changes in their cutting blades.

Apical extrusion of debris and irrigant using novel preparation systems

AIM

The aim of this in vitro study was to assess the amount of apically extruded debris and irrigant using Reciproc vs self-adjusting fle (SAF) and to investigate the effect, if any, of gravitational force via mandibular and maxillary positioning of the teeth.

MATERIALS AND METHODS

Forty human mandibular premolars were randomly assigned to four groups of 10 teeth each. The root canals were instrumented according to the manufacturers' instructions using the Reciproc and SAF. Sodium hypochlorite was used as the irrigant. The apically extruded debris was collected in pre-weighted glass vials using the Myers and Montgomery method, and teeth were placed in vials both in downward and upward positions. After drying, the mean weight of debris was assessed with a microbalance and statistically analyzed using two-way ANOVA with Bonferroni correction.

RESULTS

All instrumentation techniques and positions caused measurable apical extrusion of debris. A significant difference was observed according to position and instrument used (p < 0.05). The Reciproc extruded significantly more debris than SAF and vial downward position extruded significantly more debris than upward position (p < 0.05).

CONCLUSION

Under the conditions of this study, all systems caused apical debris extrusion, especially in the downward position.

CLINICAL SIGNIFICANCE

According to results of this study, the SAF was associated with less debris extrusion compared to the Reciproc in both mandibular and maxillary positions.

Cleaning capacity of hybrid instrumentation technique using reamer with alternating cutting edges system files: Histological analysis

Aim:

The aim of the following study is to evaluate the cleaning capacity of a hybrid instrumentation technique using Reamer with Alternating Cutting Edges (RaCe) system files in the apical third of mesial roots of mandibular molars.

Materials and Methods:

Twenty teeth were selected and separated into two groups (n = 20) according to instrumentation technique as follows: BioRaCe - chemomechanical preparation with K-type files #10 and #15; and files BioRaCe BR0, BR1, BR2, BR3, and BR4; HybTec - hybrid instrumentation technique with K-type files #10 and #15 in the working length, #20 at 2 mm, #25 at 3 mm, cervical preparation with Largo burs #1 and #2; apical preparation with K-type files #15, #20, and #25 and RaCe files #25.04 and #30.04. The root canals were irrigated with 1 ml of 2.5% sodium hypochlorite at each change of instrument. The specimens were histologically processed and photographed under light optical microscope. The images were inserted onto an integration grid to count the amount of debris present in the root canal.

Results:

BioRaCe presented the highest percentage of debris in the apical third, however, with no statistically significant difference for HybTec (P > 0.05).

Conclusions:

The hybrid technique presented similar cleaning capacity as the technique recommended by the manufacturer.

Shaping ability of nickel-titanium rotary instruments in curved root canals

INTRODUCTION

Disinfection and subsequent obturation of the root canal space require adequate mechanical enlargement of the canals. The purpose of this in vitro study was to compare the shaping ability of Mtwo, RaCe and Medin rotary instruments during the preparation of curved root canals.

MATERIALS AND METHODS

Sixty mesiobuccal root canals of mandibular molars with severe curvatures between 25-35(°) and radius of 4-9 mm were randomly divided into three groups of 20 canals each. Using pre- and post-instrumentation radiographs, straightening of the canal and the apical transportation were determined with AutoCAD software. The data were analyzed using Chi square, analysis of variance, and post-hoc tests and the significance level was set at P<0.05.

RESULTS

Mtwo instruments maintained the canal curvature significantly better than Race and Medin instruments (P<0.05). There was significant difference between the rotary instruments for iatrogenic transportation of the major foramen (P>0.05).

CONCLUSIONS

Under the conditions of this in vitro study, Mtwo instruments seemed superior to the two other rotary instruments.

Comparison of influence of different manufacturing methods on the cleaning efficiency of rotary nickel-titanium files

The purpose of this study was to evaluate and compare cleaning effectiveness of TwistedFile, GT series X, Revo-S, RaCe, Mtwo, and ProTaper Universal rotary files in curved canals. Seventy mesiobuccal canals of extracted human first maxillary molars were divided into seven groups of 10 samples each. Canals were prepared with six nickel-titanium (NiTi) rotary systems and manual K-Flexofile. Irrigation was performed with 2 mL 2.5% NaOCl solution after each file, and 5 mL 2.5% NaOCl was used for the final flush. After the roots were split longitudinally, the presence of debris and smear layer was visualized using scanning electron microscopic photomicrographs taken at coronal, middle, and apical third. Mean scores for debris and the smear layer were calculated and statistically analyzed for significance between groups using the Kruskal-Wallis nonparametric analysis of variance (P < 0.05) and Mann-Whitney U test (P < 0.001). There was no significant difference among the groups in terms of debris and smear layer scores (P > 0.05). Without considering the preparation method used, while no statistically significant difference was found between the coronal third and the middle third (P > 0.05), higher amount of debris and smear layer were found in apical third (P = 0.001). The new generation of NiTi rotary files including the Twisted File and GT Series X presented similar cleaning effectiveness compared with traditionally ground NiTi rotary files.

The effect of single-file reciprocating systems on Substance P and Calcitonin gene-related peptide expression in human periodontal ligament

AIM

To quantify the effect of two single-file reciprocating root canal preparation systems on Substance P (SP) and Calcitonin gene-related peptide (CGRP) expression in healthy human periodontal ligament (PDL).

METHODOLOGY

Forty PDL samples were obtained from healthy premolars where extraction was indicated for orthodontic reasons. Prior to extraction, 20 of these premolars were divided equally in two groups, and then, root canals were prepared using one of two different single-file systems: WaveOne and Reciproc. Ten premolars were prepared with hand files and served as a positive control group. The remaining 10 premolars where extracted without treatment and served as a negative control group. All PDL samples were processed, and SP and CGRP were measured by radioimmunoassay.

RESULTS

Greater SP and CGRP expression were found in the hand instrumentation group (1.220 pmol SP and 0.084 pmol CGRP per mg of PDL), followed by the WaveOne group (0.908 pmol SP and 0.046 pmol CGRP per mg of PDL) and the Reciproc group (0.511 pmol SP and 0.022 pmol CGRP per mg of PDL). The lower SP and CGRP values were associated with the intact control group (0.453 pmol SP and 0.018 pmol CGRP per mg of PDL). The Kruskal-Wallis test revealed significant differences between groups (P < 0.001). Post hoc Tukey HSD tests revealed significant differences in SP and CGRP expression between intact teeth in the control group and all the other groups (P < 0.001) except with the Reciproc group (P = 0.165 and P = 0.42 for SP and CGRP, respectively). Hand instrumentation was associated with significant differences with all the other groups (P < 0.001). Differences between the WaveOne and Reciproc groups were also significant (P < 0.001).

CONCLUSION

Substance P and CGRP expression in PDL cells increased when teeth were prepared with WaveOne as well as with hand instrumentation. Reciproc maintained SP and CGRP levels in line with the negative control group.