Is it possible to reduce file numbers of conventional ... · 2 Özel Fab Ağız ve Diş Sağlığı...

Is it possible to reduce file numbers of conventional rotary

systems?

Gül Celik Corresp., 1 , Murat Maden 1 , Ahmet Savgat 2 , Hikmet Orhan 3

1 Faculty of Dentistry, Endodontics, Suleyman Demirel University, Isparta, Turkey2 Özel Fab Ağız ve Diş Sağlığı Merkezi, Antalya, Turkey3 Department of Biostatistics and Medical Informatics, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey

Corresponding Author: Gül CelikEmail address: [email protected]

Backround: frequent introduction of new dental instruments or devices into the market has been aconcern for dentists worldwide, as the prices of such instruments are generally high, especially indeveloping countries. In addition, the use of these tools requires new skills and experience. For thisreason, while innovations in dentistry are being pursued, it may be advantageous to update the dentalinstruments that we have been using for years. This study evaluated whether both ProFile and ProTaperfiles have the potential to reduce the number of files required for shaping curved root canals.

Methods: A total of 45 simulated canals with 40o curvature in clear resin blocks were prepared withconventional rotary systems: ProFile orifice shaping (OS) #3 and final flaring #25/.06, Reciproc R25, andProTaper shaping file SX and finishing file F2. Pre- and post-instrumentation views were analysed usingdigital images captured by a camera. Prepared inner and outer walls at 1–10 levels were measured usingAutoCAD software. The time required for canal shaping and the frequency of broken instruments wererecorded. Standardised pre- and post-instrumentation radiographs were taken to determine changes inworking length (WL) and straightening of canal curvature. The presence of blockage or perforation wasalso evaluated. Data were analysed using the one-way multivariate analysis of variance (ANOVA) andleast significant difference test. The level of significance was set at 0.05. The transportation,instrumentation time, change of WL, and instrumentation fractures were evaluated. Data were analysedby ANOVA, Kruskal–Wallis and independent t-test (p<0.05).

Results: Reciproc removed more mass in total and caused less transportation in the middle and coronalthird (p<0.001). The transportations performed in the apical third were opposite to the curve. There wasno significant difference among the groups in terms of maintaining the original WL. Reciproc wassignificantly faster (p<0.001). Only one instrument fracture (25/0.06 ProFile) was noted. All groupsshowed one ledge each.

Discussion: According to this study, both ProFile and ProTaper files have the potential to reduce thenumber of files required for shaping curved root canals. However, Reciproc, which was produced using asingle-file concept, was determined to be more advantageous in terms of time. This study suggests thatthe conventional rotary technique system might have comparable efficacy to the single-file system forroot canal shaping.

PeerJ Preprints | https://doi.org/10.7287/peerj.preprints.26641v1 | CC BY 4.0 Open Access | rec: 8 Mar 2018, publ: 8 Mar 2018

1 Full Title: Is it possible to reduce file numbers of conventional rotary systems?

2 Authors: Gül Çelik1, Murat Maden1Ahmet Savgat2 Hikmet Orhan3

3 Institutional Affiliations:

4 1DDs, PhD Department of Endodontics, Faculty of Dentistry, Suleyman Demirel University,

5 Isparta, Turkey

6 2 Private Practise

7 3 Department of Public Health, Faculty of Medicine, Suleyman Demirel University, Isparta,

8 Turkey

9 Running Title: Preperation techniques

10 Key words: Reciproc, ProTaper, ProFile, shaping ability, single file

11

12 Corresponding author:

13 Gül Çelik

14 Department of Endodontics

15 Faculty of Dentistry

16 Suleyman Demirel University, 32260

17 Isparta, Turkey

18 Phone: +905324730823

19 Fax: +902462370607

20 Email: [email protected]

21 [email protected]

22

23


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25 Is it possible to reduce file numbers of conventional rotary systems?

26 Backround: frequent introduction of new dental instruments or devices into the market has been

27 a concern for dentists worldwide, as the prices of such instruments are generally high, especially

28 in developing countries. In addition, the use of these tools requires new skills and experience.

29 For this reason, while innovations in dentistry are being pursued, it may be advantageous to

30 update the dental instruments that we have been using for years. This study evaluated whether

31 both ProFile and ProTaper files have the potential to reduce the number of files required for

32 shaping curved root canals.

33 Methods: A total of 45 simulated canals with 40o curvature in clear resin blocks were prepared

34 with conventional rotary systems: ProFile orifice shaping (OS) #3 and final flaring #25/.06,

35 Reciproc R25, and ProTaper shaping file SX and finishing file F2. Pre- and post-instrumentation

36 views were analysed using digital images captured by a camera. Prepared inner and outer walls

37 at 1–10 levels were measured using AutoCAD software. The time required for canal shaping and

38 the frequency of broken instruments were recorded. Standardised pre- and post-instrumentation

39 radiographs were taken to determine changes in working length (WL) and straightening of canal

40 curvature. The presence of blockage or perforation was also evaluated. Data were analysed using

41 the one-way multivariate analysis of variance (ANOVA) and least significant difference test. The

42 level of significance was set at 0.05. The transportation, instrumentation time, change of WL,

43 and instrumentation fractures were evaluated. Data were analysed by ANOVA, Kruskal–Wallis

44 and independent t-test (p<0.05).

45 Results: Reciproc removed more mass in total and caused less transportation in the middle and

46 coronal third (p<0.001). The transportations performed in the apical third were opposite to the


47 curve. There was no significant difference among the groups in terms of maintaining the original

48 WL. Reciproc was significantly faster (p<0.001). Only one instrument fracture (25/0.06 ProFile)

49 was noted. All groups showed one ledge each.

50 Discussion: According to this study, both ProFile and ProTaper files have the potential to reduce

51 the number of files required for shaping curved root canals. However, Reciproc, which was

52 produced using a single-file concept, was determined to be more advantageous in terms of time.

53 This study suggests that the conventional rotary technique system might have comparable

54 efficacy to the single-file system for root canal shaping.

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70 Introduction

71 Single-file systems appeal to dentists, because they are less expensive and time-consuming due

72 to the use of fewer tools and they avoid cross-contamination while preventing possible prions.

73 However, the cost is still high and many instrument fractures occur (1). Therefore, manufacturer

74 usually changes the number, shape and design of instruments to be used in root canal preparation

75 in accordance with the basic principles of endodontics.

76 Given this situation, some researchers evaluated their rotary motion activities by reducing

77 the number of traditional files, such as ProTaper and ProFile. Subsequently, the advantages of

78 reciprocating movement against rotary motion came to the fore again, and traditional files were

79 evaluated for reciprocating motion. Finally, the new generation of single-file system took its

80 place in the market.

81 A recent development in canal shaping techniques was described by Yared in 2008 using a

82 single NiTi file in a reciprocating motion to prepare curved canals in molar teeth (2). Several

83 studies have reported satisfactory results using ProTaper F2 (Dentsply Maillefer, Ballaigues,

84 Switzerland) in a reciprocating motion when cyclic fatigue resistance and shaping ability were

85 measured (3-5). Based on these results, it may be possible for canal shaping using a conventional

86 rotary NiTi file system in a reciprocating motion to be applied clinically.


87 ProTaper F2 cannot shape the canal to full length when it is used in a conventional

88 continuous rotating motion. However, few studies have applied a reciprocating motion to

89 conventional rotary NiTi files like ProTaper F2 (6).

90 A while ago, nickel-titanium-based Reciproc (VDW, Munich, Germany), which shaped

91 root canals with a single file, was introduced to the dental market. This file is made from a

92 nickel-titanium-based m-wire subjected to a special heat treatment. The greatest feature of the

93 M-wire nickel-titanium alloy is resistance to cyclic fatigue and greater flexibility of the

94 instrument (7). The reciprocal movement is similar to the first application of balanced force

95 introduced in 1985 by Roane et al. (8), and it allows for its use in automatic devices and even in

96 severely curved root canals. The reciprocation working motion is the clockwise movement

97 (release of the instrument) and the counter-clockwise movement (cutting direction). The

98 clockwise counterclockwise angle is greater than clockwise.The manufacturer does not require

99 the use of a glide path in the use of Reciproc files (9).

100 The ProFile, first introduced by Schilder in 1992, is the most researched canal instrument

101 (10, 11), and it is accepted as the gold standard (12).

102 Up to now, few studies on reciprocation or rotary movement with ProTaper F2 files have

103 been reported (3,11,13). However, no study has investigated the shaping ability of a conventional

104 full-sequence rotary instrument ProFile in single-file systems. The purpose of this study is to

105 evaluate whether it is possible to reduce the file number of conventional rotary systems and to

106 compare these systems with Reciproc.

107 Methods


108 Forty‐five simulated root canals in resin blocks (Lot 1118484 Dentsply Maillefer) were

109 operated for this study. The curvature of J-shaped simulated canals was 40 degrees with respect

110 to Schneider Method and the length of the canals was 16.5 mm (14).

111 Groups PRF (ProFile orifice shaping (OS) #3 and final flaring #25/.06 (Lot 4259530

112 Dentsply Tulsa Dental, Tulsa, OK)) and PRT (ProTaper shaping file SX and finishing file F2

113 (Lot 1154441 Dentsply Maillefer)) were instrumented with continuous rotary movement by an

114 electric motor (Technika; ATR, Pistoia, Italy) set at a speed of 300 rpm and torque of 30

115 (Technika motor setting value) in a 16:1 reduction handpiece. Group RR (Reciproc R25 (Lot

116 160072 VDW, Munich, Germany, Dentaire Company, la‐Chaux‐de‐Fonds, Switzerland)) was

117 instrumented with a reciprocating movement using a VDW Silver motor (VDW GmbH)

118 according to the manufacturer’s instructions.

119 The patency of the canals was confirmed with a #10 stainless steel K‐file (Lot 1185265

120 Dentsply Maillefer) and then irrigated abundantly with saline. Each file was discarded after

121 being used in 5 canals.The preparation time was notted in seconds by one of the authors. The

122 preparation time also included the time needed to irrigation the canals, change the instruments,

123 and check the apical patency.

124 Assessment of Canal Preparation

125 All groups were carried out by a author with 10 years of experience, and examination of

126 canal morphology before and after instrumantation was performed by another blind author

127 according to the experimental groups.

128 All prepared canals were assessed using composite images of pre- and post-

129 instrumentation. A camera (Canon EOS 500D DSLR, Tokyo, Japan) secured at a fixed distance


130 (32 cm) from a microscope stage was used to capture the images, which were then saved on a

131 desktop computer. To help align pre- and post- instrumentation photographs, each block was

132 marked with 10 reference points. The composite images were analysed using image analysis

133 software (AutoCAD, Silver Spring, MD, USA).

134 AutoCAD (Autodesk, San Rafael, CA) software, a measurement scale was also arrenged.

135 Then, these images were transferred to same software, and the levels of blocks removed were

136 computed at 20 points (10 inner and 10 outer points). The points of measurement were defined in

137 1-mm intervals; points 0 to 3 established the apical part, points 4 to 6 constituted the coronal

138 part, and points 7 to 10 established the coronal plane part of the canal.

139 The distance was measured between the inner limit of the initial canal and the inner limit

140 of the instrumented canal (A) and between the outer limit of the initial canal and the outer limit

141 of the instrumented canal (B). The following equations were used to determine transportation

142 and the total amount of dentin removed:

143 Transportation:丨A − B丨(A result of ‘0’ indicates no transportation

144 Total amount of dentin removed: A + B

145 Statistical Analyses

146 Statistical analyses of data obtained in this study were carried out according to SPSS 21

147 (IBM SPSS Inc., Chicago, IL) software. Data were analysed according to the one-way

148 multivariate analysis of variance (ANOVA) and least significant difference test. The level of

149 significance was set at 0.05.

150 Results


151 Mean values and standard deviations of width values of canals shaped are presented in

152 Table 1. ProFile was found to create statistically significantly smaller enlargement values in total

153 and at all parts of canals (p<0 .001).

154 The direction and amount of canal transportation (mm) at the different measurement points

155 are presented in Figure 1 and Figure 2. ProFile caused less transportation in total and in the

156 coronal part (p<0.001). Reciproc caused less transportation in the middle part, and the

157 transportations were performed opposite to the curve (p<0.05). ProTaper caused more

158 transportation in the apical part (p<0.001).

159 There was no significant difference among the groups in terms of maintaining the original

160 working length (WL). The average WL loss of all groups was only 0.3 mm. Reciproc was

161 significantly faster (23 s±4.4), followed by ProFile (52.8 s±3.7) and ProTaper (104.4s±16.5)

162 (p<0.001). Only one instrument fracture (25/0.06 ProFile) was noted. Canal irregularity was not

163 observed in any group, whereas all groups showed one ledge each.

164 Discussion

165 The frequent introduction of new dental instruments or devices into the market has been a

166 concern for dentists worldwide, as the prices of such instruments are generally high, especially in

167 developing countries. In addition, the use of these tools requires new skills and experience. For

168 this reason, while innovations in dentistry are being pursued, it may be advantageous to update

169 the dental instruments that we have been using for years. In this article, the shaping capacities of

170 conventional instruments and those of ProFile instruments, which are considered the gold

171 standard, have been reviewed once again.


172 All dentists know that root canal shaping is the most time-consuming and exhausting part

173 of root canal treatment. The manufacturers have not been able to introduce new equipment and

174 tools in the dental market. For this purpose, changes were made to the cross-sections of root

175 canal files, and new alloys are on the agenda. It was revolutionary for endodontists when

176 manufacturers first marketed nickel-titanium instruments and then added a motor to the system.

177 Later, the files used with this engine system started to create some disadvantages for

178 endodontists. The more tools that are broken, the more difficult they are to remove, which

179 increases the number of tools used and the expense. Meanwhile, the reciprocating motion used in

180 the Giromatic system has started to regain popularity.

181 The experiment with shaping of root canal with a single file first started with the F2

182 ProTaper in reciprocating motion (2, 3,11,13). Afterwards, by utilising the advantages of m-wire

183 alloys, single-file systems were marketed commercially. Some research has been performed on

184 the shaping capabilities of these instruments, and the results have been quite satisfactory (4,5,9).

185 However, these instruments in a reciprocating motion were presented two drawbacks. First, the

186 likelihood of instrument fracture is due to the relative hardness resulting from the size, taper and

187 cross-section of the instrument, rather than cyclic fatigue. Second, it makes it necesseray for

188 creating a glide path with additional hand files before using the F2 instrument in a reciprocating

189 motion (2). It has been reported that 15 K file can be used safely at reciprocal movement, with

190 the prevention of apical transportation, in the preparation of a glide path (5).

191 The reciproc with a #15 or #20 K-File glide path had similar shaping performance to other

192 comparable file systems in the preparation of mandibular molars (6,15-17). Various gide paths

193 created with pathfiles were advantageous in creating minimal apical transportation, and


194 reciprocating single-file system were relatively centralized in the canal and there was not

195 difference between these pathfile files used in straight canals (18).

196 Although glide path techniques have been proposed in single file systems, some studies

197 have shown satisfactory results when these files are not used. The Reciproc without a glide path

198 maintained the original canal curvature well and was safe to use (9, 19). The F2 without glide

199 path preparation has created satisfactory root canal shaping as well as the full-sequence ProTaper

200 system (11). In this study, glide path preparation was not performed.

201 Some authors suggested preflaring of the coronal porion of the canal before the files are

202 working to prevent undesirable situations that may occur during canal preparation (20, 21). Since

203 ProFile is in more frequent contact with the dentin because of its larger radial fields, the tip of

204 the instrument may bind in the canal; in this study, ProFile OS 3 files were used for coronal

205 expansion to overcome undesired deformities. Likewise, in the ProTaper group, the SX file was

206 used for coronal enlargement.

207 According to the results of the present study, statistically significantly less resin was

208 removed at all measurement points in the ProFile group than in the Reciproc group (p<0.05). The

209 amount of substance removed from root canals depends on the depth of penetration of the

210 rotating instruments and the shapes of the instruments used. The convex triangular sections of

211 ProTaper increase the cutting efficiency of the instrument. Moreover, the taper of the instrument

212 ranges from 0.08 to 0.19, which is greater than that of ProFile and equal to that of Reciproc when

213 used at the same level in the canal. However, the amount of substance removed was greater than

214 the amounts reported in other studies (5, 11, 16, 22). This can be performed by increasing the

215 instrument’s duration of use in the canal.


216 Apical canal transportation is an undesirable deformity that is affected by a wide variety of

217 factors, such as the type of instrument, size, and type of alloy, instrumantation technique, or

218 curve of the canal. Transportation can lead to debris and the presence of uncleaned canals that

219 contain microorganisms that have not been destroyed or that have not been neutralized, or which

220 can distort the integrity of the root (i.e. an apical or strip perforation) and create hermetically

221 incapable canal (23).

222 Canal transportation may result in inadequately cleaned root canals harbouring debris and

223 residual microorganisms, over-reduction of sound dentin with a possible outcome of reduced

224 fracture resistance and destruction of the integrity of the root (i.e. an apical or strip perforation)

225 (23).

226 Previously, it has been reported that apical sealing may be adversely affected if apical

227 transport is greater than 0.3 mm (24). No transportation value recorded in this study exceeded

228 this limit.

229 ProFile caused less transportation overall and in the coronal part (p<0.001). Reciproc

230 caused less transportation in the middle part, and the transportation was performed opposite to

231 the curve (p<0.001). ProTaper caused more transportation in the apical part (p<0.001).

232 The shaping ability of ProFile instruments has been investigated in a number of studies. In

233 general, this system minimizes the apical transportation by maintaining the original canal

234 curvature well.(25-28). These good features are believed to originate from the cross-section of

235 the instrument, which is a radial area that allows the instrument to remain in the center of the

236 canal by rotating 360 degrees (29). This section helps prevent undesired deformations (30). In

237 the literature, there has been no study of the performance of the ProFile alone or in combination

238 with an additional auxiliary canal insturment as pathfile.


239 There are several methods of examining canal transportation, including radiographic

240 imaging, cross-sectioning, computed tomography (CT), micro CT, cone beam CT (CBCT), and

241 the use of simulated root canals (9, 11, 31). Resin blocks were preferred in this study, as they can

242 simulate canals and are more successful in providing standardisation. In the literature, there is no

243 information on transportation with the F2 in which resin blocks were selected as the investigation

244 method. This also applies in part to Reciproc. Therefore, we could not make an exact

245 comparison. However, a small number of studies in which other investigative methods were used

246 present data indicating that the F2 ProTaper transports at an acceptable level (2,4,11,16). In this

247 study, although the maximum apical transport was observed with the F2, this amount remained at

248 the critical level determined by Wu et al. (24). There are many studies in the literature on

249 Reciproc, the first single-file system on the market. It has been shown that the shaping ability of

250 this file, which usually completes the shaping quickly, is satisfactory (6, 9, 15-17, 22).

251 The full-sequence ProTaper approach with Reciproc using CBCT straightened root canal

252 curvatures similarly and created alike canal transportation with the other five files in the

253 preparation of mesial canals of mandibular molars (16. In a similar study, Bane et al. (32)

254 reported that ProTaper straightened the root canal to a greater extent.

255 In the present study, only one file was fractured in the ProFile group, whilst danger zone

256 formation in one block and ledge formation in another block were recorded in the Reciproc

257 group. Reciproc was significantly faster (23s ± 4.4), followed by ProFile (52.8s ± 3.7) and

258 ProTaper (104.4s± 16.5) (p<0.000). In agreement with these findings, it was reported that

259 Reciproc instruments prepared canals significantly faster than other instruments.

260 Conclusions


261 According to this study, both ProFile and ProTaper files have the potential to reduce the

262 number of files required for shaping curved root canals. However, Reciproc, produced using a

263 single-file concept, was determined to be more advantageous in terms of time. This study

264 suggests that the conventional rotary technique system might have comparable efficacy to the

265 single-file system for root canal shaping.

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Figure 1(on next page)

The direction and amount of canal transportation (mm) at the different measurement

points.

Values were calculated by subtracting the amount of resin removed at the inner side

(concavity of the apical curvature) of the simulated canal from the amount of resin removed

at the outer side.


Figure 2(on next page)

The direction and amount of canal transportation (mm) at the three parts and in total


Table 1(on next page)

Means (mm) and Standard Deviations at the Different Measurement Points and

Segments of Canal Width after Preparation with the Different Instruments.


1 Table 1 Means (mm) and Standard Deviations at the Different Measurement Points and Segments of Canal Width after

2 Preparation with the Different Instruments

ProFile Reciproc ProTaper

1 0,18± 0,04b 0,24± 0,02a 0,25± 0,05a

2 0,22± 0,04b 0,30± 0,03a 0,31± 0,03a

3 0,24±0,04b 0,33± 0,02a 0,33± 0,03a

4 0,64± 0,10b 0,87± 0,04a 0,89± 0,08a

5 0,27± 0,04b 0,39± 0,02a 0,38± 0,05a

6 0,31± 0,05b 0,44± 0,03a 0,40± 0,03a

7 0,37± 0,05c 0,48± 0,03a 0,45± 0,04b

8 0,92±0,09c 1,31± 0,06a 1,23± 0,08b

9 0,40± 0,04a 0,48± 0,03b 0,50± 0,05b

10 0,41± 0,04c 0,48± 0,03b 0,54± 0,06a

Apical part 0,64± 0,09b 0,87± 0,04a 0,89± 0,08a

Middle part 1,21± 0,16b 1,71± 0,07a 1,67± 0,12a

Coronal part 2,11± 0,20b 2,75± 0,11a 2,71± 0,12a

Total 3,14± 0,33c 3,96± 0,20b 4,47± 0,20a

Values with different superscript letters were statistically different (P < 0.001).

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