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University of Khartoum

The Graduate collage


Medical and health studies board

An In vitro Comparison between Endodontic Hand and


Rotary Instruments in Root canal Preparations.

By:
Azza Abdelrawouf Dafalla
B.D.S (U of K)

A thesis submitted in partial fulfillment of the requirements


For the Degree of Master in Conservative Dentistry,
Faculty of dentistry, University of Khartoum

Supervisor:
Prof. Yahia Eltayeb Ibrahim
BDS, FFDCSI (UK)

January 2009
Table of Content

Abstract............................................................................................................................... 4
Abstract(Arabic) .6
1 CHAPTER ONE - INTRODUCTION AND LITRETURE REVIEW . 12
1.1 INTRODUCTION: ........................................................................................... 13
1.2 OBJECTIVES OF THE STUDY:..................................................................... 15
1.3 Literature Review.............................................................................................. 16
1.3.1 Technical goals of canal preparation:.................................................................................. 18
1.3.2 Iatrogenic damage caused by root canal preparation: ........................................................ 19
1.3.3 Manual instrumentation techniques: .................................................................................... 21
1.4 Endodontic hand instruments:........................................................................... 23
1.4.1 Conventional stainless steel root canal instruments: ........................................................... 24
1.4.2 Flexible stainless steel root canal instruments:.................................................................... 26
1.4.3 Titanium-based root canal instruments:............................................................................... 27
1.4.4 New geometrical shapes for endodontic instruments: .......................................................... 28
1.4.5 Studies in root canal preparation using K-files:................................................................... 30
1.5 Endodontic rotary instruments:......................................................................... 32
1.5.1 Rotary nickel titanium files:.................................................................................................. 33
1.5.2 Canal preparation technique for rotary instrumentation: .................................................... 34
1.5.3 A novel canal preparation technique: .................................................................................. 36
1.5.4 Types of rotary files:............................................................................................................. 36
1.5.5 The GOLD standard:............................................................................................................ 37
1.5.6 Preparation sequence:.......................................................................................................... 39
1.5.7 Studies in root canal prepration using Profile 0.04: ............................................................ 40
1.5.8 General considerations for rotary instrumentations: ........................................................... 42
1.6 Hand instrument versus rotary:......................................................................... 43
1.7 Criteria for assessment the quality of root canal preparation: .......................... 49
1.7.1 Methodological aspects in assessment of preparation quality ............................................. 49
1.7.2 Evaluation of post-operative root canal shape:.................................................................... 50
1.7.3 Evaluation of safety issues:................................................................................................... 53
1.7.4 Evaluation of working time:.................................................................................................. 54
2 CHAPTER TWO - MATERIALS AND METHODS ......................................... 56
2.1 Material and methods:....................................................................................... 57
2.1.1 Study area:............................................................................................................................ 57
2.1.2 Study sample:........................................................................................................................ 57
2.1.3 Study design: ........................................................................................................................ 57
2.1.4 Materials: ............................................................................................................................. 56
2.1.5 Samples preparations: .......................................................................................................... 59
2.2 Examination of results: ..................................................................................... 64
2.2.1 Preparation time: ................................................................................................................. 64
2.2.2 Canal blockage:.................................................................................................................... 65
2.2.3 Loss of working distance: ..................................................................................................... 65
2.2.4 Instruments failure: .............................................................................................................. 65
2.2.5 Canal form: .......................................................................................................................... 65
2.3 Statistical analysis:............................................................................................ 66
3 CHAPTER THREE - RESULTS .......................................................................... 67
3.1 Results:.............................................................................................................. 68
3.1.1 Preparation time: ................................................................................................................. 68

2
3.1.2 Canal blockage:.................................................................................................................... 69
3.1.3 Change of working distance: ................................................................................................ 69
3.1.4 Instruments failure: .............................................................................................................. 70
3.1.5 Canal form: .......................................................................................................................... 74
4 CHAPTER FOUR DISCUSSION, CONCLUSION AND
RECOMENDATION...................................................................................................... 84
4.1 Discussion:........................................................................................................ 85
4.2 Conclusion: ....................................................................................................... 89
4.3 Recommendation: ............................................................................................. 90
5 CHAPTER FIVE - REFERENCE ..................................................... 90
5.1 References:........................................................................................................ 92
Appendix A................................................................................................................... 98
Appendix B ................................................................................................................. 104

3
Abstract

Objectives: This study aims to compare hand stainless steel K-files and
Nickel titanium Profile 0.04 taper 29 series rotary instruments in root canal
preparation on permanent premolars. For their efficiency in canals shaping
with maintenance of original canal shape, procedural errors that occur during
preparations of the canals or the instruments and time consumed in canals
preparation by both methods.

Materials and methods: About 46 freshly bilaterally extracted first


premolars for orthodontic purpose were selected. They were further divided
into two groups, each group comprise 23 teeth with sum of 34 canals, group
I and group II. In group I teeth were prepared with hand stainless steel k-
files and group II were prepared with profile 0.4 taper series 29 rotary files.
Impression material were introduced to the lumen of the prepared canals and
the three dimensional shape of the prepared canals were assessed under
magnification of stereomicroscope to assess the efficiency in preparing
canals including canal smoothness, flow and taper.

Results: results showed significantly shorter preparation time for Profile


0.04 taper than that of K-file. During canals preparations, about 8.8% of
canals prepared with hand K-file showed canal blockage, change of working
distance appeared in 23.5% of canals prepared with K-file and 11.7% in
canals prepared with Profile. Failed instruments were significantly higher in
K-files; the failure was in the form of deformation in most of cases. Profiles
failed instruments were in the form of fracture and no deformation detected.

4
Both systems showed unsatisfactory quality of walls smoothness and flow.
Good taper characteristic were highly significant in K-files preparations.
Conclusion: Profile 0.04 rotary files prepared canals quicker than hand K-
files and showed less instruments failures. Stainless steel K-file showed
better results in regard to canals taper, suggesting the use of a technique that
combines the two systems in canals preparation to overcome problems
associated with each system.

5

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0.4 29 . ,

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6
DEDICATION

To my parents

for their constant support and sacrifices.

To my husband Ayman and daughter Fatima

for their encouragement to pursue higher studies.

To my supervisor and co supervisor,

Whose guidance, encouragement,

kind help and support made this project

possible.

7
ACKNOWLEDGEMENTS

I owe my supervisor Prof. Yahia Al tayeb, and my Co-Supervisor Dr.Nemat

Abubakr, deep gratitude. They have always inspired and encouraged me to think.

I was never deprived of their valuable views and suggestions which helped me

not only in this thesis work but also during my entire course of post graduation.

I would like to thank the Dean Mr.Ahmad suliman for his continuous

encouragement.

I would like to express my gratitude to Dr. Aber Ali, for her kind hearted co-

operation during my thesis work and during my entire postgraduate study.

I would like to thank my cousin Mr. Abdalla Elshaikh, UNDP for his help with data

analysis.

I would like to thank Dr. Nuha Abdelrahman for helping me with the assessment

of my samples.

Words are all I have to say a big thank you to my friends, the assistants in the

clinic and the Genetics lab for the stereomicroscope work.

8
Many other people have been responsible for helping me during my thesis work

and in my study period. I deeply appreciate all of them for their whole hearted

support.

I thank Allah for showing his blessings on me and showing me the right

path.

Azza Abdelraouf Dafalla

9
LIST OF TABLES

Table Legend Page


1
Comparison of canals blockage by debries following 68
instrumentations with K-files and Profiles prepared canals.

2
Change in working distance in canals prepared with K-file and 69
Profile

3
Mean change in working distance in canals prepared with K-file and 70
Profile.

4
Quantity and quality of instruments failure in canal prepared with 71
K-File and Profile.

5
Assessment of the apical stop from impression of canals prepared 74
with K-File and Profile.

6
Assessment of apical smoothness from intracanls impression 75

7
Assessment of coronal smoothness from intracanals impression 76

8
Assessment of vertical and horizontal grooves from intracanal 78
impressions.
9
Assessment of flow characteristic from intracanal impressions 79

10
Assessment of canal taper from intracanal impressions 81

10
LIST OF FIGURES:

Figure Legend Page

1 Materials used in the study 58

2 Samples embedded in resin blocks 59

3 Access cavity to all samples 60

4 Sample preparation 61

5 Samples with intracanal impression in canals


lumen. 62

6 Final intracanal impressions


62

7 Sample under magnification of stereomicroscope 63

63
8
Apical part of canals impression under
magnification

11
Figure Legend Page

9 Comparison of mean preparation time between stainless steel hand 69


K-file and profile 0.04taper rotary file. P value < 0.005, (significant).

10 Comparison of instruments failure between the K-file and Profile in 72


canals preparation, P value <0.005 (significant).

11 Final canals impressions for single rooted and double rooted first 73
premolars.
8
12 An intercanal impression under the magnification of 73
stereomicroscope.

13 Comparison of apical and coronal smoothness in canals prepared


with K-file and Profile, P value >0.005 (not significant). 77

14 Comparison of Flow characteristic in canals prepared with K-file


and Profile. P value > 0.005, (not significant). 80

15
Comparison taper characteristic in Canals prepared with K-file and 82
Profile. P value < 0.005, (significant).

12
1 CHAPTER ONE - INTRODUCTION AND LITRETURE
REVIEW

13
1.1 INTRODUCTION:

The technical demands and level of Precision required for successful


performance of endodontic procedures have traditionally been achieved by
careful manipulation of hand instruments within the root canal space and by
strict adherence to the biologic and surgical principles, essential for
disinfection and healing. To improve the speed and efficiency of the
treatment, recently there has been a shift from using manual methods to
rotary system for both preparation and sealing of root canal system. Stainless
steel instruments have been used in a variety of preparation techniques, in an
attempt to produce the appropriate shape. However, studies have shown that
procedural incidents occur commonly, producing aberrations such as
formation of hourglass-shaped canals, zips, elbows and canal
transportation.[1-3]

Nickel titanium (Ni-Ti) rotary instruments reduced such aberrations.


Furthermore, Ni-Ti instruments maintain the original canal shape during
preparation and have a reduced tendency to transport the apical foramen [4-6]
With all these apparent advantages, the use of Ni-Ti rotary systems has
increased considerably since their introduction. However, their cost,
[7-9]
instrument fracture and their tendency to straighten in severely curved
canals leading to loss of original canal shape[10-13] are notable disadvantages.
Although few studies have been carried out into the shaping ability of rotary
nickel titanium files, they have been shown to be faster than hand
[10, 14, 15]
preparation, potentially reducing patient and dentist fatigue.
This shift from manual root canals preparation to rotary instrumentation
also took place among dentists in Sudan reasoning that, it is more accurate

14
and less time consuming. On the other hand, the conventional hand
instruments are still the most common used for canals preparation in dental
schools and general dental practices.

The aim of this present study is to asses the efficiency of these rotary files,
in comparison to conventional hand files in root canals preparation.

15
1.2 OBJECTIVES OF THE STUDY:
General objectives:

The study aims to compare the conventional manual method in root canal
preparation and the machined method with rotary files in vitro.

Specific objectives:

To compare between manual root canal preparation using stainless steel K-


files with the engine driven method using Profile 0.04 taper 29 series, in
permanent premolars;

1. For their efficiency in Canals preparation


maintaining the original canal shape.
2. In procedural errors that occur during
preparations
3. In time consumption during preparation.

16
1.3 Literature Review
Root canals and Endodontic history:

The word "endodontic" comes from two Greek words meaning "inside" and
"tooth." Around the second or third century B.C. a skull found in Palestines
Negev Desert had a bronze wire in one of its teeth, which, researchers
believe, may have been used to treat an infected pulp and could be the first
traces of endodontics. In a survey of endodontic instrumentation up to 1800,
it was concluded, that at the end of the 18th century only primitive hand
instruments and excavators, some iron cauter instruments and only very few
thin and flexible instruments for endodontic treatment had been available.
Indeed, Edward Maynard has been credited with the development of the first
endodontic hand instruments. In 1852 Arthur used small files for root canal
enlargement. In 1885 the Gates Glidden drill and in 1915 the K-file were
introduced. Although standardization of instruments had been proposed in
1929 by Trebitsch and again by Ingle in 1958, ISO specifications for
endodontic instruments were not published before 1974.The first description
of the use of rotary devices seems to have been by Oltramare. He reported
the use of fine needles with a rectangular cross-section, which could be
mounted into a dental handpiece. In 1889 William H. Rollins developed the
first endodontic handpiece for automated root canal preparation. A period of
modified endodontic handpieces began with the introduction of the Canal
Finder System by Levy. It was an attempt to make the root canal anatomy
or at least the root canal diameter one main influencing factor on the
behavior of the instrument inside the canal. Richman described the use of
ultrasound in endodontics but it was mainly the work of Martin &
Cunningham in the 1970s that made ultrasonic devices popular for root canal

17
preparation. Since 1971 attempts have been made to use laser devices for
root canal preparation and disinfection. Instruments made from nickel
titanium (NiTi), first described as hand instruments by Walia et al in 1988,
they have had a major impact on canal preparation. While hand instruments
continue to be used, NiTi rotary instruments and advanced preparation
techniques offer new perspectives for root canal preparation that have the
potential to avoid some of the major drawbacks of traditional instruments
and devices.[16]

Endodontic instruments:

It is defined as an instrument used in the debridement of root canals and


shaping them in a way that makes them suitable for receiving root canal
filling. Until 1960, root canal instruments were produced of carbon steel,
which is now replaced by stainless steel alloys. Manufactures have
developed new stainless steel alloys characterized by higher flexibility in
bending compared with conventional stainless steel instruments to avoid
undesirable shaping effects and removing excessive amount of tooth
materials from curved canals. Up to now, even flexible stainless steel
instruments with non-cutting tips have not produced entirely enlargements of
severely curved Canals In order to overcome this problem, modifications of
stainless steel instruments, characterized by lower (E) module have been
developed. Then, highly flexible instruments were made of new alloy the
Nickel-Titanium (NiTi). NiTi was developed by W. F. Buehler in early
1960, which is non-magnetic, salt resisting and water-proof alloy. This new
combination alloy had unique properties of shape memory and super
elasticity, which makes engine-driven instruments feasible. With this new

18
technique, there was significant reduction in preparation time and better-
cleaned and shaped root canals.

1.3.1 Technical goals of canal preparation:

The technical goals of canal preparation are directed toward shaping the
canal so as to achieve the biological objectives and to facilitate placement of
a high quality root filling. Schilder in 1974, [17] recognized that canal shaping
should be performed with respect to the unique anatomy of each root and in
relation to the technique of root canal filling. IN addition, Schilder also
outlined several mechanical objectives for optimal instrumentation:
i. Continuously tapering funnel from the access cavity to apical foramen.
A continuously tapering preparation facilitates efficient delivery of
antimicrobial irrigant and creates resistance form against which to compact a
root filling.
ii. The root canal preparation should maintain the path of the original canal.
Canal systems move through multiple geometric planes and curve
significantly more than the roots that house them. The use of inflexible
instruments to prepare a curved canal results in uneven force distribution in
certain contact areas and a tendency of the instrument to straighten itself
inside the root canal. As a result, the apical canal is transported toward the
outer curvature while coronally the canal is transported toward the
concavity. This transported canal thus adopts an hour-glass shape, and may
suffer from inadequate debridement as well as complications such as
ledging, root perforation, or excessive thinning of canal walls.
iii. The apical foramen should remain in its original position.
Canal transportation may result in damage to the apical foramen, creating a
characteristic elliptical shape known as a foraminal rip, zip, or tear. Wu et al

19
[18]
demonstrated in vitro that apical transportation negatively impacted on
apical seal when curved canals were obturated by lateral compaction of gutta
percha.
iv. The apical opening should be kept as small as practical enlargement of
the canal should be in keeping with biological requirements.

1.3.2 Iatrogenic damage caused by root canal preparation:

Weine et al[19], Glickman & Dumsha [20]


have described the potential
iatrogenic damage that can occur to roots during preparation with
conventional steel instruments and included several distinct preparation
errors:
Zip:
Zipping of a root canal is the result of the tendency of the instrument to
straighten inside a curved root canal. This results in over-enlargement of the
canal along the outer side of the curvature and under-preparation of the inner
aspect of the curvature at the apical end point. The main axis of the root
canal is transported, so that it deviates from its original axis. The terms
(teardrop) and (hour-glass shape) are used similarly to describe the resulting
shape of the zipped apical part of the root canal.
Elbow:
Creation of an (elbow) is associated with zipping and describes a narrow
region of the root canal at the point of maximum curvature as a result of the
irregular widening that occurs coronally along the inner aspect and apically
along the outer aspect of the curve. The irregular conicity and insufficient
taper and flow associated with elbow may jeopardize cleaning and filling the
apical part of the root canal.

20
Ledging:
Ledging of the root canal may occur as a result of preparation with
inflexible instruments with a sharp, inflexible cutting tip particularly when
used in a rotational motion. The ledge will be found on the outer side of the
curvature as a platform, which may be difficult to bypass as it frequently is
associated with blockage of the apical part of the root canal. The occurrence
of ledges was related to the degree of curvature and design of instruments.
Perforation:
Perforations of the root canal may occur as a result of preparation with
inflexible instruments with a sharp cutting tip when used in a rotational
motion. Perforations are associated with destruction of the root cementum
and irritation and/or infection of the periodontal ligament and are difficult to
seal. A consecutive clinical problem of perforations is that a part of the
original root canal will remain un- or underprepared if it is not possible to
regain access to the original root canal apically of the perforation.
Strip perforation:
Strip perforations result from over-preparation and straightening along the
inner aspect of the root canal curvature. These midroot perforations are
again associated with destruction of the root cementum and irritation of the
periodontal ligament and are difficult to seal. The radicular walls to the
furcal aspect of roots are often extremely thin and were hence termed danger
zones.
Outer widening:
Outer widening describes an over-preparation and straightening along the
outer side of the curve without displacement of the apical foramen. This
phenomenon until now has been detected only following preparation of
simulated canals in resin blocks.

21
Apical blockage:
Apical blockage of the root canal occurs as a result of packing of tissue or
debris and results in a loss of working length and of root canal patency. As a
consequence complete disinfection of the most apical part of the root canal
system is impossible.
Damage to the apical foramen:
Displacement and enlargement of the apical foramen may occur as a result
of incorrect determination of working length, straightening of curved root
canals, over-extension and over-preparation. As a consequence irritation of
the periradicular tissues by extruded irrigants or filling materials may occur
because of the loss of an apical stop. Besides these classical preparation
errors insufficient taper (conicity) and flow as well as under- or over-
preparation and over- and underextension have been mentioned in the
literature[16]

1.3.3 Manual instrumentation techniques:

Historically, a variety of different techniques have been developed


specifically for preparation of canals using stainless-steel hand files.[16]
The step-back technique:
It was described by Mullaney in 1978; it is involved in preparation of the
apical region of the root canal first, followed by coronal flaring to facilitate
obturation. When employed in curved canals, this technique often results in
iatrogenic damage to the natural shape of the canal due to the inherent
inflexibility of all but the smallest stainless steel files. [21]
The step-down techniques:
These techniques were developed in an effort to reduce the incidence of
iatrogenic defects which commence preparation using larger instruments at

22
the canal orifice and then work down the root canal with progressively
smaller files. [22]
Pre-enlarging the coronal region of the canal prior to
completing apical preparation provides several advantages, including
straighter access to the apical region, enhanced tactile control, as well as
improved irrigant penetration and suspension of debris. Studies have shown
that step-down techniques produce fewer canal blockages, less apically
extruded debris, and a reduced incidence of apical transportation when
compared to step-back techniques. [3]
The modified double flare technique:
The coronal portion of the canal is initially instrumented. The canal
preparation progress in a stepdown fashion in 1 mm increments with each
smaller file size until the WL is reached. The canal is then enlarged
sequentially to desired file size at WL. The taper of the canals is then refined
by stepping back in 1 mm intervals with each larger file size. [23]

The Balanced force technique: This technique, was reported by Roane &
Sabala in 1985, it was originally associated with specially designed stainless-
steel or NiTi K-type instruments (Flex-R-Files) with modified tips in a
stepdown manner. Instruments are introduced into the root canal with a
clockwise motion of maximum 180 and apical advancement (placement
phase), followed by a counterclockwise rotation of maximum 120 with
adequate apical pressure (cutting phase). The final removal phase is then
performed with a clockwise rotation and withdrawal of the file from the root
canal. Apical preparation is recommended to larger sizes than with other
manual techniques, e.g., to size #80 in straight canals and #45 in curved
canals. The main advantages of the balanced force technique are good apical
control of the file tip as the instrument does not cut over the complete length,

23
good centering of the instrument because of the non-cutting safety tip, and
no need to pre-curve the instrument.

In recent times the introduction of NiTi alloy has permitted the manufacture
of extremely flexible instruments which are capable of safely preparing
curved canals with less straightening compared with stainless steel
instruments.[24] Accordingly, traditional instrumentation techniques such as
the step-back method are now phasing out because of the increasing and
expanding use of NiTi instruments. It must be realized, however, that
because of their extreme flexibility, NiTi instruments are not designed for
initial negotiation of the root canal, nor for bypassing ledges.

1.4 Endodontic hand instruments:

Concerning root canal instruments for manual use, two major innovations
have been made during recent years: first, highly flexible instruments made
of new alloys like nickel-titanium have been developed and second, new
geometrical shapes, such as modified instrument tips or instruments with
short cutting segments, have been introduced. In principle, root canal
instruments can be subdivided into three different types. These are reamers,
K-files and Hedstrom files. Several modifications to these three types have
been displayed.[25] The basic design of stainless steel endodontic files and
reamers used manually was patented in 1917; Specification and tolerances
for files and reamers were accepted in 1976 by the ANSI/ADA after Ingle &
Levine first suggested standardization. Subsequently, specification no. 28 for
files and reamers was again revised in 1981 and the revision covered criteria
such as diameter, length, taper, stiffness, inspection procedures and
sampling. During the late 1980s and early 1990s, significantly modified

24
endodontic instruments were designed, tested and marketed. At that time,
Walia et al described the first highly flexible nickel-titanium files.[16]

1.4.1 Conventional stainless steel root canal instruments:

1-Broaches: Barbed broaches are used primarily for the removal of intact
pulp tissue from large canals. They are thin, flexible, usually tapered and
pointed, smooth or with a series of sharply pointed barbed projections
curving backward and obliquely. The identification symbol of barbed
broaches is an eight-pointed star formed by the barbs. Smooth broaches can
be used as explorers to get the feel of the canal.
2- K-Reamers: are used to enlarge the pulp canal after broaches have been
used. Reamers may be used with a reaming action (rotary cutting) or a filing
action (scraping or pulling stroke
3- Files: Root canal files are normally used after the broaches and reamers.
The root canal files look much like those of the reamers. However, the file
threads or cutting edges are much finer and closer together. Files come in
two different types (H and K types) and are different in terms of physical
properties, such as flexibility, resistance to fracture in rotation, and
method of manufacture. The designation of "K-type" or "H-type" is a
generic classification based on a manufacturing process and does not
apply to any single design or line of instruments. Numerical size
designations and color coding are the same for both file types. Sizes begin
with size 8 and continue through size 140. Files come in different lengths,
including 19 mm, 21 mm, 25 mm, and 31 mm.
K-files: The K-type was introduced in the beginning of the century and
designed by Kerr manufacturing Co (Romulus, Michigan, USA). It
is tapered and pointed, with tight spiral cutting edges arranged so that the

25
cutting occurs on either a pushing or pulling stroke. They are used to
enlarge the root canal by a rotary cutting or abrasive action. When
pulling the instrument out of the tooth, the cutting edges scrape against the
wall, gouging and removing dentin in a filing action. The identification
symbol of k-files is a square.[25]
H-files: The H-type are tapered and pointed, with spiral cutting edges
arranged so that cutting occurs principally on the pulling stroke. These files
also known as "Hedstrom" are used to enlarge the root canal by either a
cutting or an abrasive action. The series of intersecting cones forming the
file become successively larger from the tip toward the handle. The
sharp blades of the H-type files cut more quickly than reamers or K-files.
The H-type files are frequently used for flaring of the canal from the apical
region to the occlusal or incisal opening. The identification symbol for H-
type files is a circle.

1.4.2 Flexible stainless steel root canal instruments:


In order to avoid undesirable shaping effects in curved root canals, such as
straightening, ledging, zip and elbow formation, several manufacturers have
developed new stainless steel alloys characterized by higher fiexibility in
bending compared with conventional stainless steel instruments .These so-
called flexible stainless steel instruments are similar in shape to conventional
reamers and K-files.

Flexicut: (VDW) made of a chrome-nickel steel,They are triangular in


cross-section

26
Flexoreamer: (Maillefer) The cross-section of this twisted instrument is
triangular. the Flexoreamer displays by far the highest cutting efficiency of
all hand instruments .
K-Flex file: (Kerr). This instrument is fabricated of V-4 steel and the
cross-section is rhombus-shaped to enhance flexibility and cutting
efficiency.
K-Flexofile: (Maillefer) sizes 15 to 40. The cross-section of this twisted
instrument is triangular. Independent of instrument size, the working end has
They show better cutting efficiency and enhanced flexibility compared with
conventional stainless steel instruments.

1.4.3 Titanium-based root canal instruments:


Besides the modifications of the geometrical shape of the stainless steel
instruments, recently, new alloys characterized by lower E modulus, have
been developed for root canal instruments in order to overcome undesirable
shaping effects especially in severely curved canals. Some of these
instruments use titanium, and a distinction has to be made between nickel-
titanium alloys and titanium-aluminum alloys.

Nickel-titanium root canal instruments:


Several manufacturers have started to produce nickel-titanium (Nitinol)
instruments. These Nitinol hand instruments are being fabricated in a U- and
S-shaped configuration and as K-files and Hedstrom files. Owing to their
substantially increased flexibility compared with stainless steel instruments,
nickel-titanium based instruments are reported to be particularly suitable for
preparing curved root canals. Nickel-titanium instruments are shown to have

27
about three times the elastic flexibility in bending and torsion of the stainless
steel files. ,

The NiTi S hand file is made by grinding a circular tapered blank into a
double helix fluted pattern. The helical angle is closer to an H-file than a K-
file and this may explain the improved cutting efficacy of S-files in linear
motion. Preparation with Ni-Ti K-files produced more appropriate shapes in
roots with apically curved canals than Ni-Ti S-files.

1.4.4 New geometrical shapes for endodontic instruments:

Instruments with short cutting segments:


To enhance instrumentation results in curved canals, instruments with
short cutting segments have been developed.
Canal Master U (Brasseler USA, Savannah, Georgia,USA).
Flexogates (Maillefer).
Heliapical (Micro Mega).

Safety Hedstrom files:


The Safety Hedstrom file was introduced in endodontics by the Kerr
Manufacturing Co. in 1993. The spiral of the working end of the Safety
Hedstrom files is characterized by a noncutting side with smoothened edges
(safe-side) to prevent ledging in curved canals.
ProFile Series 29" instruments:
The concept of the ProFile 29 instruments is based on the assumption that
the incremental changes at diameter 1 with instruments manufactured
according to the ISO specification are too large, especially at the beginning
of the series, i. e., between ISO sizes 10 and 25. For example a size 15

28
instrument is 50% wider than the size 10 instrument, whereas the percentage
difference between an ISO size 60 and size 55 instrument at point d 1 is a
mere 9%. Compared with this, the newly designed ProFile 29
instruments show a constant percentage increment of 29.17% at d1
between successive instruments. The outcome of this constant percentage
change is a parabolic increase in instrument size. ProFile 29 instruments are
numbered #00, #0 and then #1 to #11. The # 1 instrument corresponds
exactly to the ISO size 10 and the #8 corresponds to the ISO size 60. To
enlarge a root canal with a diameter of 0.1 mm at the apical constriction up
to a diameter of 0.6 mm, 10 instruments manufactured according to the
current ISO specification are necessary, whereas only 8 instruments
constructed according to the new sizing are necessary. According to
[26]
Schilder, the ProFile Series 29 offers two major advantages compared
with the current endodontic armamentarium: first, the instruments are better
spaced within the useful range, with more instruments at the beginning of
the series and fewer at the end; and second, fewer instruments are necessary
to go from the narrowest to the widest instrument .

Root canal preparation using traditional stainless-steel ISO 0.01 tapered


instruments by hand very often results in iatrogenic damage to curved root
canals. A further disadvantage is their tendency to create narrow canal
shapes which makes effective access for irrigants more difficult and apical
extrusion of debris more likely. The major advantage of NiTi alloy is its
ability to retain flexibility with increased taper. This has resulted in the
development of two groups of NiTi hand instruments
The GT Instruments which have 26 times the taper of ISO 0.02 files and
Hand ProTaper which have a variable taper. Both are used with a crown

29
down sequence. These NiTi Hand instrumentation methods leave good
tactile feedback and the start-up costs are low. They are an excellent
teaching tool and a useful introduction to NiTi Rotary Techniques. They can
be used exclusively or in conjunction with or complementary to rotary
techniques. Hand NiTi instruments can be selected in teeth with difficult
canal anatomy, secure apical curvature or awkward access for a hand
piece.[27]

1.4.5 Studies in root canal preparation using K-files:

1-Shaping abilities:
Shaping of curved canals with K-flles manipulated in a linear flling motion
proved a satisfactory method to maintain the original canal curvature.[17] In
comparing of nickel-titanium K-files, stainless steel reamers, K-files, and
flexible stainless steel instruments[28]it is found that the best instrumentation
results were obtained with flexible instruments with noncutting tips.
2-Cutting efficiency:
When used in linear motion, H-files are more efficient than reamers or K-
files, cutting away more root canal dentine than K-files. [29]
Schafer et al [28]

have studied the cutting efficiency of K-Flex files and conclude that the K-
Flex files display higher cutting efficiency than conventional stainless steel
reamers, K-files and the fiexible ,Flexicut, but lower cutting efficiency than
Flexoreamers and K-Flexofiles. But is superior to the no standardized
ProFile Series 29 instruments with regard to cutting efficiency and
instrumentation of curved canals.[30]
3-Procedural errors:
Distinct transportation of canals is reported when using K-flles with a
rotational cutting action in combination with a longitudinal flling motion. [28].

30
Stainless steel files were well known that they tend to create aberrations in
canals[1-3, 31],
4-Bending and torsional properties:
The average resistance to bending of K-flles is less than that of reamers.
Concerning torque and angular deflection, in most cases K-files reach
greater angular deflection than reamers of the same brand.[28] Nickel-
titanium, titanium aluminum, and flexible stainless steel instruments
displayed lower torque values than conventional stainless steel K-files and
reamers.[32] In general, it appeared that the propensity of stainless steel files
to create aberration is the result of their inherent stiffness of the metal which
confounded by instruments design and canal shape. [33]
5-Morphometrical properties:
K-type files, Sureflex NiTi files, and FlexoFiles were evaluated
morphometrically as they come from the manufacturer, and after being used
to instrument root canals 1, 3, and 5 times in maxillary premolars. It was
concluded that small-sized stainless-steel instruments should be discarded
after one use. On the other hand, #30 stainless-steel K-files could be used up
to three times and #30 stainless-steel FlexoFiles up to five times. Sureflex
NiTi instruments, even after five times, did not show appreciable
abnormalities in shape. It is strongly recommended that small-sized nickel-
titanium instruments should be discarded after five uses.[11]
6-Effect of sterilization:
Sterilization can lead to considerable corrosion damage to carbon steel
instruments, whereas no significant effects on the mechanical properties of
stainless steel instruments. Several authors demonstrated that different
sterilization procedures of stainless steel instruments produced surface
changes resulting in a decrease in cutting efficiency and micro hardness. [34]

31
1.5 Endodontic rotary instruments:

The first description of the use of rotary devices seems to have been by
.
Oltramare He reported the use of fine needles with a rectangular cross-
section, which could be mounted into a dental handpiece. These needles
were passively introduced into the root canal to the apical foramen and then
the rotation started. In 1889 William H. Rollins developed the first
endodontic handpiece for automated root canal preparation. He used
specially designed needles, which were mounted into a dental handpiece
with a 360 rotation. To avoid instrument fractures rotational speed was
[35]
limited to 100 r.p.m. In the following years a variety of rotary systems
were developed and marketed using similar principles. The introduction of
engine-driven instruments in tapers greater than the standard 2% taper in
1992 by Dr Wm. Ben Johnson substantially changed the way root canal
preparation was accomplished. These instruments made it possible to create
an appropriately flared canal shape without the need for time-consuming
serial stepback shaping procedures.

Gates Glidden and pesos reamers are stainless steel endodontic drills. They
are of the first intercanal rotary instrument invented in 1885; their primary
job is for canal shaping rather than post insertions. Gates Glidden Used for
opening the orifice of the root canal. In case of binding, the drill will fracture
near the latch for easy retrieval. They are made of stainless steel. Peeso
Reamers: Ideal for widening and paralleling root canals for post core
preparations.

32
1.5.1 Rotary nickel titanium files:

The introduction of Nickel titanium, or NiTi, rotary instrumentation has


made endodontics easier and faster than hand instrumentation, resulting in
consistent and predictable root canal shaping. The rotary technique is less
fatiguing for the practitioner and NiTi decreases postoperative pain for the
patient, most likely due to a combination of file design and a crown-down
modality.

Properties of Ni-Ti:


NiTi is extremely flexible; it is five times more flexible than stainless
steel and appears to be 10 times more resistant to stress.[32]
The metal is superelastic and has the additional property of shape
memory. Research investigations have proven that NiTi is
biocompatible and anticorrosive and does not weaken following
sterilization.[36] However, it is not easy to manufacture.
This alloy can exist in either one of two crystalline phases. When
NiTi file is at rest, it is in the austenite stage. When this alloy is
torqued and placed under stress, it transforms into martensite; this is
known as a martensitic deformation and is typical of alloys that are
superelastic. When the file is fluctuating between transformations (for
example, while rotating and being torqued within a canal), the
instrument is more susceptible to permanent deformation and fracture
or separation. This problem can be alleviated by understanding
respective system usage and limitations, using consistent and constant
revolutions per minute, using unstressed files and passively using files
to resistance rather than forcing them.

33
Files operated with torque-control electric engines. The advantage of a
torque-control engine is that when a file is stressed beyond a certain
preset limit, the file will automatically reverse and, in certain cases,
back itself out of the canal. This is a decided safety factor and
obviously beneficial for the practitioner. Torque-control engines will
continue to evolve to the point where the engines will be able to
recognize the various files when placed in the contra-angle handpiece.
This is where technology is heading in modern endodontics.

1.5.2 Canal preparation technique for rotary instrumentation:

The crown-down method allows for a more efficient mechanism to shape


canals, irrespective of whether stainless steel or NiTi files are used, hand or
rotary. However, due to the absolute necessity to limit stress on NiTi files
and due to the availability of increased tapers, crown-down is an essential
principle of all NiTi rotary techniques[37] . By using a crown-down technique,
the cervical constricture is eliminated and the coronal dentin is passively
removed with larger files or reamers in turn, a smaller file proceeds
unhindered into the apical third of the canal, resulting in increased tactile
awareness in the apical third of the canal. When increased irrigation efficacy
is combined with a rotary file that helps pull debris coronally, there appears
to be less postoperative discomfort. Traditionally, Gates-Glidden drills,
Pesso reamers and even large files have been used to enlarge the coronal
portion of the root canal. Hand instruments such as K-type files, reamers and
Hedstroms as well as sonics have been used to instrument the body of the
canal; apical preparation historically has been performed with either K-type
files or reamers.

34
New technology, however, has resulted in the use of NiTi rotary files
throughout the entire body of the root canal. This ability to use NiTi rotaries
in such a manner is a result of both the material and design of the
instruments. Currently, there are tip designs in both cutting and noncutting
modes, the noncutting tip being the safer. The practitioner can also select
cutting edges that can be neutral in design or slightly more positive.
Additionally, some files have incorporated radial lands into their design. The
radial lands, particularly in combination with noncutting tips, help maintain
file centering in the root canal, significantly reducing canal transportation.

Irrespective of the system chosen, rotary instrumentation results in a


consistent and smooth preparation. For the practitioner, NiTi rotary
instrumentation helps reduce hand fatigue and enhances practice efficiency.
[10, 14, 15]
The improved flexibility and unique properties of NiTi alloy provides
an advantage when preparing curved canals and has made it possible to
engineer instruments with greater tapers (412 per cent), thereby allowing
[38].
better control of root canal shape. The result is a predictably machined
tapered preparation that facilitates cleaning of the canal and its subsequent
obturation. Due to such characteristics nickel-titanium instruments have
gained rapid acceptance among endodontists in recent years. However,
before introducing these instruments into routine patient treatment, clinicians
should consider that much of the evidence on the properties of Ni-Ti
instruments has been derived from in vitro studies on extracted teeth, and
their claimed superiority with respect to conventional stainless steel
instruments has still to be conclusively proven .[39]

35
1.5.3 A novel canal preparation technique:

A novel canal preparation technique with only one Ni-Ti rotary instrument
used in a clockwise and counterclockwise movement is described by Yared
in 2008. This technique would offer two major advantages: (i) the single use
of endodontic instruments would become more cost effective and (ii) the
elimination of possible prion cross-contamination and a reduced instrument
fatigue associated with the single use of endodontic hand and rotary reamers
and files. The preliminary experience with this technique and the first
impression were encouraging. However, the need of proper laboratory and
clinical evaluation of several parameters (apical extrusion of debris,
incidence of instrument fracture, canal transportation, need of preflaring,
etc) would be essential.[40]

1.5.4 Types of rotary files:

Currently, there are a large number of rotary systems available, these


systems differ in cross section, radial angles and taper.The most famous
among these systems include:

Profile Rotary System (Dentsply Tulsa),


Profile GT Rotary System (Dentsply Tulsa),
Quantec Series 2000 (Analytic Endodontics),
Lightspeed System (Lightspeed),San Antonio USA)
Power-R System (Moyco/Union Broach).
FlexMaster (VDW, Munich, Germany)
HERO 642 (Micro-Mega, Besancon, France).
Mtwo . (Sweden & Martina, Padova, Italy)

36
Race (RaCe; FKG Dentaire, La-Chaux-de-Fonds, Switzerland).
K3 0.04 taper instruments (Sybron-Endo, CA, USA)
ProTaper (Dentsply Maillefer)
McXIM series (Tulsa Dental, OK, USA).

1.5.5 The GOLD standard:

The ProFile series has been the most widely researched nickeltitanium
rotary instrument in endodontics over the last 10 years establishing it as the
gold standard against which others are measured. Introduction of these
rotary instruments has enabled practitioners to provide a more predictable
level of care to patients in a more timely and reproducible manner and has
caused a paradigm shift in the way endodontic treatment is accomplished
and has raised the standard of care[41]. This low incidence of profile
instruments fractures suggested its continuous use in root canal treatment
as well as the use by dental students in laboratories if preventive methods
are used.[42, 43]

The ProFile .04 Taper Series 29: It is a nickeltitanium engine driven U


file, developed from the original Profile Series 29 hand instruments.
According to the manufacturer, the 0.04 tapered instruments flutes have flat
outer edges (radial lands) to prevent threading into the canal and bullet-
nosed tips to prevent ledging, zipping and transportation. The file has twice
the taper of ISO instruments and a constant 29% increase in tip diameters
between sizes that range from 2 to 10. The rationale behind this paradigm
shift provided the operator with more instruments of smaller tip size to be
used in the delicate apical anatomy, while fewer larger instruments were
necessary coronally, where flexibility is of less concern. The series also

37
decreased the number of instruments used in canal preparation. These Series
29 ProFiles (Dentsply Tulsa Dental) were introduced in 1993 with a 0.04
taper, while instruments with .06 taper were added later. In due course, a
more traditional ISO series of ProFile instruments with conventional sizes
was manufactured and marketed by Dentsply Maillefer (Ballaigues,
Switzerland) along with a series of Orifice Shapers. The latter instruments
are similar to ProFile but, in general, have large tip diameters, shorter cutting
blades and greater tapers. More recently, ProFile instruments with a 0.02
taper were introduced to provide a comprehensive range of tapers that are
capable of dealing with most canals shapes. The use of Series 29 instruments
initially presented some difficulties, with the non-standard tip size, the
change in the file numbering system and the use of metallic colors
designating size. These factors produced a system that had a steep learning
curve and as such Series 29 ProFiles were mostly the purview of specialists.
The introduction of ISO tip diameters simplified their adoption to a wider
range of general dentists and specialists. The flutes of ProFile instruments
have radial lands that cut radicular dentine with a neutral rake angle,
planning the walls smooth and minimizing canal transportation. A tip with
no sharp transitional line angles further enables the instrument to remain
centered around canal curvature virtually eliminating ledge formation. The
flutes are cut deep into the core from tip to shank allowing greater flexibility
at larger cross-sectional diameters, while allowing larger amounts of debris
to be removed. The cross-section of the instrument is referred to as a U-
blade design, and hence has passive cutting ability. [41]

38
1.5.6 Preparation sequence:

The crown-down preparation technique recommended today for most rotary


nickeltitanium systems was popularized by ProFile rotary instruments.
GatesGlidden drills were supplemented or replaced with ProFile Orifice
Shapers. Orifice Shapers share the same U-blade design permitting straight-
line access to the coronal and middle thirds without encroaching on the so-
called danger zone, which may occur with GatesGlidden drills. The use of
viscous chelating agents and Orifice Shapers can effectively extirpate the
vital pulp from the canal. After coronal flaring with Orifice Shapers and
initial scouting of the canal shaping with the ProFile instruments can
commence. Several instrumentation sequences have been described for
ProFile, including the variable taper sequence, the variable tip sequence and
a sequence that alternates between .06 and .04 tapers. The technique
described here consists of using decreasing tip sizes and and then decreasing
taper in accordance with current recommendations by the manufacturer. The
concept of bringing a predefined taper to the canal terminus is thus realized
through use of ProFile .06 followed by .04 taper instruments. ProFile
instruments with a .06 taper are used to refine and ensure a more consistent
flare once the apical preparation is complete. By using .06 and then .04
tapers, friction between root canal walls and the rotating instrument is
reduced and taper-lock is avoided. This phenomenon is believed to occur
when the taper of the file closely matches that of the canal, producing
greater amounts of torque on the instrument and increasing the risk of
instrument breakage. Larger tip diameters are chosen initially to prepare the
middle and coronal third of the canal, effectively decreasing binding of
smaller instruments used later in the sequence. It should be noted that initial

39
canal entry is aided by the use of a lubricant, with copious irrigation with
sodium hypochlorite throughout the remainder of the treatment. The
estimated working length (EWL) is recorded from a well-angulated
periapical radiograph and transferred to the rubber stops of each instrument
or measured at the respective markings on the instruments shaft.

The use of the ProFile (Dentsply Tulsa Dental, Tulsa, OK, USA) instrument
sequence allowed greater predictability in canal shape allowing earlier and
deeper penetration of irrigating solutions and increased flow dynamics when
using thermoplasticized obturation materials, such as ThermaFil (Dentsply
Tulsa Dental).

1.5.7 Studies in root canal prepration using Profile 0.04:

1-Cleaning ability:

Studies on various NiTi instruments in the last years have focused on


centering ability, maintenance of root canal curvature, or working safety of
these new rotary systems; only relatively little information is available on
their cleaning ability. It should be mentioned that the term canal cleaning is
used in this review for the ability to remove particulate debris from root
canal walls with cleaning and shaping procedures. This property usually has
been determined using scanning electron micrographs These findings
underline the limited efficiency of endodontic instruments in cleaning the
apical part of the root canal and the importance of additional irrigation as
crucial for sufficient disinfection of the canal system. The comparison of
previous studies on instruments with and without radial lands (ProFile,
[44, 45]
Lightspeed, HERO 642) confirms the finding that radial lands tend to
burnish the cut dentine onto the root canal wall, whereas instruments with

40
positive cutting angles seem to cut and remove the dentine chips.
Nevertheless, it must be concluded from the published studies that the
majority of NiTi systems seems unable to completely instrument and clean
the root canal walls.[46] Comparing ProFile .04 and GT Both systems
respected original root canal curvature well and were safe to use. Smear
layer removal was not satisfactory with either systems.[47]

2-Shaping ability:

A number of articles have reported on the shaping ability of ProFile


instruments.[13] Thompson and Dummer reported that Profile 0.04 prepared
canals rapidly without creating blockage, with only limited loss in length
and with good taper and flow characteristic.[48]

3-Safty aspect of the instruments:

The maximum torsional torque values of HERO, K3 and ProTaper were


significantly higher than those of EndoWave, ProFile and K-file. The K-files
had the lowest torque value. The bending load values of HERO and K3 were
significantly higher than those of EndoWave, ProFile, ProTaper and K-file.
The K-files had the lowest load value, although residual deflection
remained. The transformation temperatures of HERO and K3 were
significantly lower than those of EndoWave, ProFile and ProTaper.[49]
Major concern has been expressed concerning the incidence of instrument
fractures during root canal preparation. Two modes of fractures can be
distinguished: torsional and flexural fractures [50, 51]
. Flexural fractures may
arise from defects in the instrument surface and occur after cyclic fatigue[52] .
The discerning feature is believed to be the macroscopic appearance of

41
fractured instruments: those with plastic deformation have fractured because
of high torsional load while fragments with no obvious signs are thought to
[50] [53]
have fractured because of fatigue. it was reported that the larger
profiles size (5, 6) were associated with more deformation than smaller files
size. Further aspects of working safety such as frequency of apical
blockages, perforations, loss of working length or apical extrusion of debris
until now have not been evaluated systematically. From the studies
described so far it may be concluded that loss of working length and apical
blockages in fact do occur in some cases, while the incidence of perforations
seems to be negligible. The amount of apically extruded debris has been
evaluated in three studies and reported to be not significantly different to
hand preparation with Balanced force motion or conventional rotary systems
[54]
using steel files . Anatomical conditions such as radius and angle of root

canal curvature, the frequency of use, torque setting and operator experience
are among the main factors, while selection of a particular NiTi system,
sterilization and rotational speed, when confined to specific limits, seem to
be less important [55], .

1.5.8 General considerations for rotary instrumentations:

The following consideration should be kept in mind when using these


instruments: [56]
Create an ideally straight coronal access.
Prior to rotary instrumentation using Ni-Ti instrument, create a glide-
path using small stainless steel instruments.
Consider the manufacturers instructions concerning the instrumentation
sequence and the frequency of use of the instrument.

42
Use each instrument not longer than 5-10 seconds inside the root canal
before removing it.
Work passively and without pressure (forced instrumentation cause canal
aberration and increase the risk of instrument separation.
Use a lubricant agent e.g. chelating agent or NaOCl) to minimize the
stress for the Ni- Ti files.
Irrigate the root canal copiously and thoroughly with sodium
hypochlorite.
Discard instrument with permanent deformation.

1.6 Hand instrument versus rotary:

1-cleaning ability:
Examining their ability to remove debris from root canals, Tan and Messer
found that instrumentation to larger file sizes using rotary NiTi instruments
resulted in significantly cleaner canals in the apical 3mm than hand. [57] It was
demonstrated that engine-driven rotary nickeltitanium instruments caused
less debris to be extruded apically than a manual push-pull or filing action.
Only the balanced force technique yielded similar amounts of apically
extruded debris to the engine-driven rotary techniques. [4]
Peters et al used
micro-CT data to analyze preparation of root canals of maxillary first molars
after instrumentation using K-type hand files and three rotary NiTi file
systems. They found that all instrumentation techniques left 35 per cent or
more of the canals dentine surface untouched, with very little difference
found between the four instrument types[58] .The results for Quantec
instruments were clearly superior to hand instrumentation in the middle and
apical third of the root canals with the best results for the coronal third of the

43
root canal. In many specimens only a thin smear layer could be detected
with many open dentinal tubules [59]. Kochis et al. [60] could find no difference
between Quantec and manual preparation using K-files. Prati et al. [61] found
no difference between stainless-steel K-files and K3, HERO 642, and RaCe
NiTi instruments.

2-Shaping ability:
NiTi rotary files have become a mainstay in clinical endodontics because of
their ability to shape root canals with fewer procedural complications.
Numerous studies using extracted human teeth have concluded that rotary
NiTi instruments maintain the canal curvature better than stainless steel
[12, 24, 62,
handinstruments, particularly in the apical region of the root canal.
63]
Esposito and Cunningham found that NiTi files became significantly
more effective than stainless steel hand files in maintaining the original
canal path when the apical preparation was enlarged beyond ISO size 30.
Collectively, in vitro studies show that NiTi instruments produce
significantly less straightening and better centered preparations than
stainless steel hand files, thereby reducing the potential for iatrogenic errors.
use of rotary instruments allowed for cleaner canals, as well as less apical
transportation and thus, less deviation from initial canal curvature [57]
.The
study by Al-Omari reported that with stainless steel hand instruments, length
was lost as a result of a combination of canal blockage, straightening of the
canal and/or the creation of aberrations such as ledges. [64]
Another study by
Schafer et al. (2004), a rare clinical study, demonstrated that rotary
instrumentation allowed for less straightening and hence better shaping of
the canal and reduced preparation time. Study results were inconclusive
regarding cleanliness of canals using either hand or rotary instrumentation.

44
Previous reports on rotary files demonstrated that they tend to create a slight
canal transportation toward the outer aspect of the curvature in the apical
region of the canals, [11, 62, 65]
Considering conservation of tooth structure,
transportation, perforation, maintenance of anatomy and time, rotary
instruments may be more efficient. However, further studies evaluating the
clinical success of automated systems.[66] are necessary before rotary
instrumentation becomes the standard of practice .Manual files and rotary
instruments yielded an equivalent degree of cleanliness however, when
shaping the canals, the best results were obtained with rotary instrument.[67]

3-Working time:

Some comparative studies have shown evidence for shorter working times
for rotary NiTi preparations when compared with manual instrumentation,
[12, 68, 69] [62, 63, 70]
other studies have shown no difference It is likely that
working time is more dependent on operator factors and the preparation
technique used rather than the instruments themselves. For example, NiTi
systems using only a small number of instruments, e.g., ProTaper will
prepare canals faster than systems using a large number of instruments, e.g,
Lightspeed. it was reported that nickel titanium rotary preparation will
reduce patient and operator fatigue whilst providing safe handling of
instruments in the hand piece[48].

4-Instrument fracture:
All endodontic instruments have the potential to break within the canal
following improper application. While it is a commonly held perception
within the dental profession that rotary NiTi instruments have an increased
frequency of breakage compared to stainless steel hand files, current clinical

45
evidence does not support this view, A review of the literature reveals that
the mean clinical fracture frequency of rotary NiTi instruments is
approximately 1.0 per cent with a range of 0.43.7 per cent In comparison,
the mean prevalence of retained fractured endodontic hand instruments
(mostly stainless steel files) is approximately 1.6 per cent with a range of
0.77.4 per cent.[71]. In light of observations that rotary NiTi files may
undergo fracture due to fatigue without prior evidence of plastic
deformation, single-use of these instruments has been advocated by some,
and there is currently no agreement as to a recommended number of uses of
these instruments [72].
Parashos et al. [73]
examined discarded rotary NiTi
instruments from 14 endodontists and identified factors that may influence
defects after clinical use. This study did not support the routine single use of
instruments to prevent fracture based on the conclusion that instrument
fracture is a multifactorial problem. The most important influence on defect
rate was found to be the operator, which may be related to clinical skill or a
decision to use instruments a specified number of times [74].

In vitro research has indicated that the main factors that may influence
fracture of rotary NiTi files include:
1-anatomical conditions such as radius [75, 76]
and angle [34,36,[77]
of root
canal curvature,
2-frequency of use,[78].
3-torque setting,[9].
4-operator experience.[79].

46
5-Instrument design impact
specific design characteristics vary, such as crosssectional geometry, tip
design, and taper, and these factors will influence the flexibility, cutting
efficiency and torsional resistance of the instrument.[80] It is recommended
that use of instruments with safety tips is preferable to those with cutting tips
such as Quantec SC which have been shown to result in a high incidence of
procedural errors including root perforation, zipping and ledging There is
[81].

some evidence that NiTi instruments with active cutting blades (e.g.,
ProTaper, FlexMaster, RaCe, Mtwo) show better canal cleanliness than
instruments with radial lands (e.g., ProFile). Comparisons of instruments
with and without radial lands ,radial lands tend to burnish the cut dentine
into the root canal wall, whereas instruments with positive cutting angles
seem to cut and remove the dentine chips [82].

In vitro studies have indicated that actively cutting cross-sections do not


seem to negatively affect centering of the canal preparation.[82] However,
instruments with active cutting blades must be used with caution in the
apical region as overinstrumentation with these instruments is likely to
create an apical zip [83].
Some studies have reported that instrument shaft
design does not significantly modify canal shapes of similar apical sizes [84]

while others have shown that a thin and flexible shaft will permit larger
apical sizes with less aberrations[85]

6-Root fracture resistance


Sathorn et al [86] found that as the size of rotary NiTi preparations increased,
the creation of a smoothly rounded canal shape served to eliminate stress
concentration sites, thereby reducing fracture susceptibility. Conversely,

47
instrumentation that leads to irregular dentine removal with canal
straightening will significantly weaken the root [87].
Lam et al found a
[88]

lower susceptibility to fracture in roots prepared with rotary NiTi


instruments compared to those prepared by hand instrumentation, and
believed that this difference was due to the rounder canal shapes produced
by rotary files leading to fewer stress concentration sites. Collectively, the
evidence indicates that apical enlargement with rotary NiTi instruments does
not weaken roots any more than conventional hand instrumentation and may
in fact increase fracture.

7-Efficiency of removing gutta-percha


In experiment were Gutta-percha was removed from single root canal
obturated teeth were the following devices and techniques were used:
ProTaper, R-Endo, Mtwo and Hedstrom files.. The ProTaper group had less
filling material inside the root canals than the other groups, but a significant
difference was found between only the ProTaper and Mtwo groups, the
ProTaper left significantly less gutta-percha and sealer than Mtwo
instruments. Complete removal of materials did not occur with any of the
instrument systems investigated.[89]

In conclusion, the sum of these studies state that NiTi rotary instrumentation
has been the driving force in changing how root canals are shaped but it is
also important to realize that there are some limiting factors associated with
NiTi. For example, NiTi rotaries cannot be used to bypass or remove ledges,
while a curved stainless steel hand file is still required to get around and
smooth out the ledge.

48
1.7 Criteria for assessment the quality of root canal preparation:

When analyzing the quality of root canal preparation created by instruments


and techniques several parameters are of special interest, particularly their
cleaning ability, their shaping ability as well as safety issues.

1.7.1 Methodological aspects in assessment of preparation quality

Over recent decades a plethora of investigations on manual and automated


root canal preparation has been published. Unfortunately, the results are
partially contradictory and no definite conclusions on the usefulness of hand
and/or rotary devices can be drawn, Major deficiencies of studies on quality
of root canal preparation include: [16]

While currently available hand instruments have been used for


almost a century, no definitive mode of use has emerged as the gold
standard. However, the Balanced force technique [90]
may be cited as
such a gold standard for ex vivo and clinical studies [6, 58].
In the majority of experimental studies published in the literature
only a small number of rotary systems or rotary techniques are
investigated and compared. Only few studies include a comparison
of four[90], [27], , five , or six and more devices and techniques.
In the majority of these published studies only some of the
parameters were investigated, thus allowing only limited conclusions
on a certain device, instrument or technique. The majority of studies
still focus on preparation shape in a longitudinal plane, whereas the
number of studies on cleaning ability remains small. This probably is
because of the fact, that the investigation of both cleaning and

49
shaping is difficult to perform in one single experimental procedure
and in any case requires two different evaluations. Data on working
time and working safety are usually not collected in separate
experiments but rather are a side-product of investigations designed
for other purposes.
A wide variety of experimental designs and methodological
considerations as well as of evaluation criteria does not allow a
comparison of the results of different studies even when performed
with the same device or technique.
Many publications do not include sufficient data on sample
composition, operator experience and training, calibration before
assessment, e.g., photographs or electron micrographs, and on
reproducibility of the results (inter- and intra-examiner agreement).
It has been criticized that in many studies preparation protocols
modified by the investigators have been introduced and evaluated
rather than the preparation protocol as suggested by the
manufacturer. This might result in inadequate use of instruments and
techniques and lead to misleading results and conclusions.

1.7.2 Evaluation of post-operative root canal shape:

The aim of studies on post-operative root canal shape is to evaluate the


conicity, taper and flow, and maintenance of original canal shape, i.e., to
record the degree and frequency of straightening, apical transportation,
ledging, zipping and the preparation of teardrops and elbows as described by
Weine et al. [19]. In the past investigations on post-operative root canal shape

50
have been performed using extracted teeth or simulated root canals in resin
blocks but this parameter can be assessed clinically as well [91].
Simulated root canals in resin blocks:
The several investigations on the shaping ability of instruments and
techniques for root canal preparation have been performed using simulated
root canals in resin blocks[10, 13, 92] . The use of simulated resin root canals
allows standardization of degree, location and radius of root canal curvature
in three dimensions as well as the tissue hardness and the width of the root
canals. Techniques using superimposition of pre- and post-operative root
canal outlines can easily be applied to these models thus facilitating
measurement of deviations at any point of the root canals using PC-based
measurement or subtraction radiography. This model guarantees a high
degree of reproducibility and standardization of the experimental design. It
has been suggested that the results of such studies may be transferred to
human teeth. Nevertheless, some concern has been expressed regarding the
differences in hardness between dentine and resin. Micro-hardness of
dentine has been measured as 35-40 kg/mm2 near the pulp space, while the
hardness of resin materials used for simulated root canals is estimated to
range from 20 to 22 kg/mm2 depending on the material used. For the
removal of natural dentine double the force had to be applied than for resin .
Additionally, it has been criticized that the size of resin chips and natural
dentine chips may be not identical, resulting in frequent blockages of the
apical root canal space and difficulties to remove the debris in resin canals.[79]
In consequence, data on working time and working safety from studies using
resin blocks may not be transferable to the clinical situation.

51
Human teeth:
The reproduction of the clinical situation may be regarded as the major
advantage of the use of extracted human teeth, in particular when set-up in a
manikin. On the other hand, the wide range of variations in three-
dimensional root canal morphology makes standardization difficult.
Variables include root canal length and width, dentine hardness, irregular
calcifications or pulp stones, size and location of the apical constriction and
in particular angle, radius, length and location of root canal curvatures
including the three-dimensional nature of curvatures. Studies on post-
operative root canal shape or changes in root canal morphology,
respectively, have been performed in mesial root canals of mandibulary
molars, as these teeth in most cases show a curvature at least in the mesio-
distal plane. Several techniques have been developed to determine the
characteristics of the curvature, the most frequently used described by
Schneider [93].
It measures the degree of the curvature in order to categorize
root canals as straight (5 curvature or less), moderately (10-20) or
severely curved (>20). More advanced techniques [94]
aim to determine
degree and radius as well as length and location of the curve(s), since all of
these factors may influence the treatment/preparation outcome. Early studies
on preparation shape were conducted using replica techniques, which are
suited to demonstrate post-operative taper and flow, smoothness of root
canal walls and quality of apical preparation. As the original shape of the
root canals remains unknown the difference between pre- and post-operative
shape cannot be evaluated with such techniques. Bramante et al. [95] were the
first to develop a method for the evaluation of changes in cross-sectional
root canal shapes. They imbedded extracted teeth in acrylic resin blocks and
constructed a plaster muffle around this resin block. After sectioning the

52
imbedded teeth horizontally the resulting slices were reset into the muffle for
instrumentation. Pre- and post-instrumentation photographs of the root canal
diameter could be superimposed and deviations between the two root canal
outlines could be measured. Subsequently, improved versions of the
Bramante technique were described.[96] The quantification of post-
operative root canal deviation may be performed using the centring ratio
method or via measurement of the pre- and post-operative dentine thickness.
This method also allows evaluation of circular removal of predentine and
cleanliness of isthmuses and recesses.

Recent technologies include the use of high-resolution tomography and


micro-computed tomography (CT). This non-destructive technique allows
measurement of changes in canal volume and surface area as well as
differences between pre- and post-preparation root canal anatomy. The
advantages of these techniques are three-dimensional replication of the root
canal system, the possibility of repeated measurements (pre-, intra- and post-
operative) and the computer aided measurement of differences between two
images. The use of micro-CT additionally enables the evaluation of the
extent of unprepared canal surface and of canal transportation in three
dimensions.

1.7.3 Evaluation of safety issues:


The main safety issues reported in studies on root canal preparation concern
instrument fractures, apical blockages, loss of working length, ledging,
perforations, rise of temperature, and apical extrusion of debris. Most of
these issues have not been investigated systematically in specially designed
investigations. In some retrospective evaluations of endodontically treated

53
teeth an incidence of instrument separation in 26% of the cases has been
reported. Instrument fractures may be related to the type, design and quality
of the instruments used, the material they are manufactured from, rotational
speed and torque, pressure and deflection during preparation, the angle and
radius of the root canal curvature, frequency of use, sterilization technique
and probably various other factors, in particular the operators' level of
expertise. No systematic investigations of instrument fracture of
conventional steel instruments or conventional automated devices could be
found in the literature, but because of their design, Hedstrom files seem to
be more prone to fracture than any other instruments [97].
A high number of
fractures were reported in ex vivo studies of rotary NiTi instruments but the
clinical incidence of such fractures has not yet been investigated.

1.7.4 Evaluation of working time:


The aim of the evaluation of working time for any instrument or technique is
to draw conclusions on the efficacy of the device or technique and on its
clinical suitability. Data on working time show large differences for identical
instruments and techniques, which is because of methodological problems as
well as to individual factors. Therefore, data from different studies should be
compared with caution, as variation caused by individuals [98]
cannot be
defined exactly but should be regarded as decisive in many cases. For
example, it was demonstrated that instrument fractures resulted in longer
working times for the following instruments in order to avoid additional
fractures For the evaluation of the efficacy of an instrument the
[99].

measurement of the cutting ability therefore seems to more appropriate[28] .


Theses studies use an electric motor driving the root canal instrument into
natural root canals in extracted teeth or artificial canals in resin blocks, thus

54
excluding individual factors. However, this does not exactly mirror the
clinical situation either.

1.8 The Cardiff experimental design:

In the recent past, four major series of standardized comparative


investigations on rotary NiTi instruments have been published. The series of
investigations used in this study are reviewed.
This series of investigations [13, 100, 101] was performed in simulated root canals.
Four types of root canals were constructed using size #20 silver points as
templates. The silver points were pre-curved with the aid of a canal former,
to form four different canal types in terms of angle and location. The four
canal types were:
Curvature 20, beginning of the curvature 8 mm from the orifice.
Curvature 40, beginning of the curvature 8 mm from the orifice.
Curvature 20, beginning of the curvature 12 mm from the orifice.
Curvature 40, beginning of the curvature 12 mm from the orifice.

The following variables and events were recorded and evaluated: preparation
time, instrument failure (deformation and fracture), canal blockage, loss of
working distance, transportation, canal form (apical stop, smoothness, taper
and flow, aberrations (zips, elbows, ledges, perforations, and danger zones),
canal width.

55
2 CHAPTER TWO - MATERIALS AND METHODS

56
2.1 Material and methods:
2.1.1 Study design:
It is an in vitro comparative experimental study. Aiming to test the
difference between using stainless-steel K-file and Profile 0.04 taper 29
series rotary Ni-Ti instruments in root canal preparation

2.1.2 Study area:


Department of conservative dentistry, faculty of dentistry,
university of Khartoum.

2.1.3 Study sample:


Forty-six freshly extracted permanent first premolars were collected. These
samples were maxillary and mandibular bilaterally extracted (for orthodontic
purpose) with complete apex formation. The proposed sample size was 60
teeth but due to insufficient resources within the time frame only 46 teeth
were collected.

2.1.4 Materials:

Stainless steel k-files size 10- 60 (Mani, Japan).

Barbed broaches, (Mani, Japan).

Profile 0.04 taper series 29 rotary file system from size 2- 8

(Dentsply, Tulsa dental USA).

Endodontic Micromotor (NSK Endomate DT, Japan).

57
Light bodied condensation silicone impression material, (Oranwash
Zhermack, Italy).

Canal lubricant, Kavo spray, (kavo ,Grmany).

Stopwatch, Sony Ericsson w810.

Stereomicroscope, (Micros, Austria).

Sodium hypochlorite2.5%. (hyposol, ST Decon Labs, Inc,USA)

Self cure white Acrylic resin, Egypt.

Tweezers, probe, syringes, ruler, glass slab, paper points and protractor.

Sample containers.

Formalin 10%. Prepared from pharmacology labs.

58
Fig.1.materials used in the study

2.1.5 Samples preparations:

Forty- six freshly extracted for orthodontic reason first permanent maxillary
or mandibular premolars (2 bilateral teeth from the same individual) were
collected and stored in 10% formalin solution immediately. The teeth were
with complete apex formation and showed total of 64 canals. Twenty- three
teeth were classified as (Group I), and the other opposing 23 teeth as (Group
II). Each group of teeth had total of 34 canals. Canals beginning of
curvature and the degree of curvature were measured for each tooth. The

59
samples in each group were randomized and blinded, Group (I) was
prepared by Conventional methods with Stainless steel hand K files , and
group II with the rotary method using nickel titanium Profile 0.04 taper 29
series , respectively.
Samples preparation was as follows:

All teeth were embedded in acrylic resin blocks. Then, Access openings to
all samples were performed; working length (WL) of each canal was
determined by placing a size 10 K- file into the canal until it is just visible at
the apical foramen. The working length (WL) was taken 1 mm short of this
point and then canals shaping and cleaning have followed (Fig.2, 3).

Fig.2: Samples embedded in resin blocks

60
Fig.3: Access cavity to all samples

2.1.5.1 Group I preparation:

For canals preparation in conventional method, modified double flare


technique by stainless steel K-files was used. Instrumentation started with
no. 15 file then enlarged to size 45 as the master apical file. The coronal
portion of the canal was initially instrumented with a size 35 K-file. The
canal preparation progressed in a stepdown fashion in 1 mm increments with
each smaller file size until the WL was reached. The canal was then enlarged
sequentially to accept a size 45 K-file at WL. The taper of the canals was
then refined by stepping back in 1 mm intervals with each larger file size
until size 60 was reached. Copious irrigation with 2.5% NaOCl was used
throughout the preparation and patency was maintained in all the canals by
recapitulation using a size 15 K file (Fig.4).

61
Fig.4: Sample preparation

2.1.5.2 Group II preparation:

Teeth were instrumented with profile 0.04 taper 29 series rotary instruments
starting from size 2 to 7 in 16:1 reduction gear handpiece .The instruments
were used according to the manufacturer instructions in a torque controlled
motor and handpiece. The Profile instruments were used in a crown-down
technique according to the manufacturer's instructions. Commencing with a
size 4 Profile 0.04 Taper, the instrument used at 280-300 r.p.m. with a slow
apical progression to 1/2-2/3 the estimated length of the canal. The process
was repeated with a size 5 file then, 6 and 7. A size 3 file was then used to
reach 2/3-3/4 of the estimated length of the canal. The definitive working
length (WL) was then determined with a size 10 K-Flex file. A size 3 file
was used to reach the WL and the canal was sequentially enlarged so that a
size 7 file reached the WL. Copious irrigation was used throughout the
procedure with 2.5% NaOCl. Patency filing was not used after each filing
but was checked at the end of the instrumentation procedure.

In all groups a new set of files was used to instrument five teeth and then
discarded.

62
The internal three-dimensional shape of all canals was determined from
intracanal impressions. A small amount of lubricant was introduced into the
canal lumen. Light bodied condensation silicone impression material was
injected carefully into each canal, followed by the introduction of a fine
barbed broach, to act as support for the coronal part of the impression and to
facilitate removal. The impressions of the prepared canals were removed and
assessed within 24 hours under the 40/0.10 magnification of
stereomicroscope (Fig.5, 6, 7).

Fig.5: Samples with intracanal impression in canals lumen.

Fig.6: Final intracanal impressions

63
Fig.7: Sample under magnification of stereomicroscope

Fig.8: Apical part of canals impression under magnification

2.2 Examination of results:

2.2.1 Preparation time:


The time taken to prepare each canal was recorded in minutes and seconds
and it included file changes within the instrumentation sequence as well as
irrigation.

64
2.2.2 Canal blockage:
Canals which became blocked with debris during preparation were noted.

2.2.3 Loss of working distance:


The final length of each canal was determined following preparation, the
master apical file was inserted into the prepared canal and its length within
the canal measured to the nearest 0.5 mm, loss of working distance was
determined by subtracting the final length from the original length.

2.2.4 Instruments failure:


Instruments were checked after every use and a record of permanent
deformation or fracture was kept, including how many times the instrument
has been used.

2.2.5 Canal form:


The impressions of the prepared canals were removed and assessed under
magnification of stereomicroscope using the following criteria (Abou-Rass
& Jastrab 1982)[102]:
1. Apical stop. Categorized as absent, present (but poorly defined) or present
(well defined).
2. Smoothness of the apical half of the canal. Categorized as
poor or good.
3. Smoothness of the coronal half of the canal. Categorized as
poor or good.
4. Horizontal or longitudinal grooves. Categorized as absent
or present.
5. Flow. Good flow characteristics are defined as a continuous blending of
the canal from orifice to apical stop. Abrupt changes in direction and the
presence of ledges give rise to poor flow characteristics.

65
6. Taper. This is categorized as good when the canal has a conical shape

throughout its length. Canals with poor taper have hourglass or cylindrical
shapes.

2.3 Statistical analysis:


Data were recorded directly on coding sheets and analyzed statistically using
SPSS 15.0 statistics software (SPSS Inc., Chicago, IL, USA) Programme,
with the assistance of a statistician, using unpaired t-test for preparation time
analysis and Chi square test and Fissures exact test for canal form analysis.
P value less than 0.0 5 will be considered as significant.

66
3 CHAPTER THREE - RESULTS

67
3.1 Results:

3.1.1 Preparation time:


Canal preparation time scored in minutes and seconds showed a mean time
of 10:02 + 3:34 SD for hand K-files preparations and mean time of 07:21+
3:04 SD for rotary Profile preparations respectively (Fig.1), P value=0.002
showed highly significant difference between the two methods in term of
preparation time. Canals with 40o curvature angulations showed mean
preparation time for K-file prepared canals of 11:01+3:49 SD, while those
prepared with Profile 0.04 showed mean preparation time of 9:06+3:06SD.

Comparisons of canals mean preparation time between K-file


Profile 0.04

12:00 10:02

9:36 7:21

7:12
Time in minutes K-file (hand)
& seconds 4:48 Profile0.04 taper (rotary)
2:24

0:00
Mean
Preparation
Time

Fig9: Comparison of mean preparation time between stainless steel hand K-file and profile 0.04taper
rotary file. P value = 0.002, (highly significant).

68
3.1.2 Canal blockage:
In hand prepared canals using k-file the results have shown that 3 out of 34
canals (8.8%) were blocked by debris. Following rotary instrumentation with
profile system, all the 34 canals remained patent (table.1).

K-file Profiles

Number of blocked canals 3 (8.8%) 0

Number of patent canals 31 (91.2%) 34 (100%)

Total number of canals 34 34

Table .1: Comparison of canals blockage by debris following instrumentations with K-


files and Profiles prepared canals.

3.1.3 Change of working distance:


The change in working distance that occurred as a result of preparation is
shown in table (2, 3). In all, hand preparation method, showed 8 of 34 canals
(23.5%) were associated with loss of distance. Three canals have showed 0.5
mm loss of WL. Three canals showed loss of 1, 2 and 3 mm respectively. In
addition, in 2 canals (5.8%) the master apical file easily passed beyond the
apex with 1 mm. From results obtained, more distances were lost from
canals with prominent curvature angulations. Overall, six of the canals that
showed change in working distance were associated with curvature
angulations of 40o. In canals prepared with profile 0.04 rotary system, results

69
showed 4 of 34 canals (11.7%) with loss of working length before the apex.
Two canals showed loss of 1mm, 2mm respectively. Moreover, two showed
loss of 2mm associated with fractured instruments. All these 4 canals were
with curvature angle of 40 o. Passing beyond the apex with the master apical
file by 1mm was reported in 3 canals (8.8%).

Change in K-file Profile

working distance (mm)

0 26 (76.5%) 27 (79.5%)

0.5 3 (8.8%) 0

1.0 3 (8.8%) 4 (11.7%)

2.0 1 (2.95%) 3 (8.8%)

3.0 1 (2.95%) 0

Total 34 34

Table 2: Change in working distance in canals prepared with K-file and Profile.

70
Numbers of Canals prepared with Canals prepared with

canals prepared K-files Profiles

34 -0.16 -0.11

Table.3: Mean change in working distance in canals prepared with K-file and Profile.

3.1.4 Instruments failure:


Hand preparations with k-file showed total of 19 failed instruments, 18 of
them (94.7%) were permanently deformed and only one instrument (5.3%)
was fractured. Size 10 k-file was deformed most frequently (6), followed by
size 15(4), size 20 (3), size 45(2), size 50(2), size 25(1) and size 35(1).
Eleven of the 19 failed instruments (57.9%) were used in preparations of
o
canals with 40 curvature, while the rest 8(42.9%) were associated with
preparation of canals with 20 0 curvature and less. Rotary preparation with
Profile in the 34 prepared canals reported only 2 canals showed failed
instruments in the form of fracture of size 3 and size 5 respectively. These 2
canals showed curvature of 40o at 8 mm. No deformed instruments reported
(table 4). Hand instrumentation showed a percentage of 90.5% (18) failure in
K-files compared to 9.5% (2) failure occurred in Profile 0.04 file. The
difference was highly significant P value< 0.001, (Fig.2).

71
K-file Profile

Number of deformed 18 0
instruments

Number of fractured 1 2
instruments

Total 19 2

Table.4: Quantity and quality of instruments failure in canal prepared by K-file and
Profile.

72
Comparsion of Instrument Failure Between K-File and Profile
During Canal Preparation

20 18

15
Number of Failed Deformed
10
Instruments Frractured

5
1 2
0
0
K-File Profile

(A)

Percentage of Instruments Failure in K-


Files and Profiles

90.50%

9.50%

K-file Profile

(B)
Fig.10 (A&B): Comparison of instruments failure between the K-file and Profile in canals
preparation, P value <0.001 (significant).

73
3.1.5 Canal form:
Quality of canal form was assessed form intracanal impression. Figures 3,4.

Fig11: 1Final canals impressions for single rooted and double rooted first premolars.

Fig12: An intracanal impression under the magnification of stereomicroscope.

74
1. Apical Stop:

The quality of apical stop for both methods of preparation is shown in


(table.5). In K-file preparations of 34 canals, apical stops were present in 26
(76.5%) canals, 16 (47%) of them were designated as poor and 10(17.6%) of

them as good. There was no apical stop in 8 (23.5%) canals. The rotary canal
preparations showed apical stop in 28 canals half of them(50%) were
designated as good and the other half (50%) were designated as poor.
Apical stops were not present in 6 (17.6%) canals. There was no significant
difference in the quality of apical stop between the canals prepared by the
two systems.

K-file Profile 0.04

Apical stop 34 canals 34 canals

Good 10 (29.5%) 14 (41.2%)

Poor 16(47%) 14 (41.2%)

Absent 8(23.5%) 6 (17.6%)

Table.5: Assessment of the apical stop from impression of canals prepared with K-file
and Profile.

75
2. Apical smoothness:

In k-file prepared canals apical smoothness was reported as good in


12(35.3%) canals out of 34 and as poor in 22(64.7%) canals. In rotary prepared
canals, about 15(44.1%) canals were of good apical smoothness and 19(55.8%)
canals showed poor apical smoothness (table 6).There was no significant
difference in quality of apical smoothness between canals prepared by the
two systems.

Apical smoothness K-file Profile

Good 12(35.3%) 15(44.1%)

Poor 22(64.7%) 19(55.8%)

Table .6: Assessment of apical smoothness from intracanls impression

76
3. Coronal Smoothness:

K-file prepared canals showed 20(58.8%) canals with smooth coronal walls.
14(41.2%) Canals showed poor coronal walls. Profile 0.04 prepared canals
showed 23(67.7%) canals with smooth coronal walls and 11(32.3%) canals
with poor coronal wall smoothness (table 7). There was no significant
difference in quality of coronal smoothness between canals prepared by the
two systems.

Coronal smoothness K-file Profile

Good 20(58.8%) 23(67.7%)

Poor 14(41.2%) 11(32.3%)

Table .7: Assessment of coronal smoothness from intracanals impression

77
A Comparison of wall smoothness for canals prepared with K-File
and Profile 0.04

100%
90%
80% 35.30% 41.20% 32.30%
70% 55.90%
60%
Number of Poor
prepared 50%
Good
40%
canals 64.75% 67.60%
30% 58.80%
20% 44.10%
10%

K-File Profile K-File Profile

Apical smoothness Coronal smoothness

B Percentage of good canal smoothness in canal prepared with K-


file and Profile 0.04 systems

100%

80%
55.60% 53.50%
60%
K-file
40% Profile 0.04
44.40% 46.50%
20%

apical coronal

Fig.13 (A&B): Comparison of apical and coronal smoothness in canals prepared with
K-file and Profile, P value >0.005 (not significant).

78
4. Vertical and horizontal grooves:

Vertical and horizontal grooves presented in 19 of 34) canals (55.9%


prepared by K-file and in 18 of 34 canals (53%) prepared by rotary profile
system table (8).

Vertical/ horizontal K-file Profile 0.04


grooves

Present 19(56%) 18(53%)

Absent 15(44%) 16(47%)

Table.8: Assessment of vertical and horizontal grooves from intracanal impressions.

79
5. Flow:

From intracanal impressions, good flow characteristics appeared in 18 (53%)


of 34 canals that were prepared with hand using K-file. The other 16 (47%)
canals were with poor flow. Fifty percent of the canals that were prepared
with profile 0.04 taper rotary files showed good flow, the other 50% showed
poor flow characteristic (table 9). There was no significant difference in the
quality of flow between the two methods of canal preparation, fig (6).

Flow K-file Profile 0.04

Good 18(53%) 17(50%)

Poor 16(47%) 17(50%)

Table.9: Assessment of flow characteristic from intracanal impressions

80
A Comparison of flow Characteristic in Canals Prepared with

K-file and Profile0.04

34
32
30
28
26 16 17
24
22
20
number of canals 18 poor
prepared 16 Good
14
12
10 18
8 17
6
4
2
0
K-File Profile

Comparison of Good Flow Characteristic in Canals Prepared with K-


B File and Profile

48.60% K-File
51.40% Profile

Fig.14 (A&B): Comparison of Flow characteristic in canals prepared with K-file and
Profile .P value >0.05 (not significant)

81
6. Taper:

Out of the 34 prepared canals in each group, the conventional hand method
produced 22 canals (64.8%) with good taper quality and 12 canals (35.2%)
with poor quality. while rotary canal preparation with Profile showed only
14canals (41.2%) with good taper and 20 canals (58.8%) with poor taper
quality( table 10). There was a significant difference in the quality of canals
taper between the two method used in preparation hence P value< 0.01.
(Fig.7).

Taper K-file Profile

Good 22(64.8%) (41.2%)

Poor 12(35.3%) 20(58.8%)

Table.10: Assessment of canal taper from intracanal impressions.

82
A comparison of canals taper between k-file (manual) and profile0.04 (rotary)
preperation

100%

80% 35.30%
58.80%
60%
number of canals
Poor
prepered
40% Good
64.80%
20% 41.20%

0%
K-File Profile

B Percentage of Good Taper Characteristic in Canals Prepared with K-


File and Profile

38.90%
K-file
Profile
61.10%

Fig.15 (A&B): Comparison taper characteristic in Canals prepared with K-file and
Profile, P value < 0.05 (significant).

83
4 CHAPTER FOUR DISCUSSION, CONCLUSION AND
RECOMENDATION

84
4.1 Discussion:
The aim of this in vitro study was to compare the use of stainless steel K
files with the use of Ni-Ti Profile 0.04 taper series 29 rotary file in root
canals preparation, in terms of walls smoothness, canals taper, flow, and
change in working distance as well as instruments failures. Bilaterally
extracted humans first permanent premolars were used under strict
laboratory condition. Previous studies used simulated canals constructed in
clear resin block with standardization of degree, location and radius of root
canal curvature, this guaranteed high degree of reproducibility and
standardization of the experimental design in assessment of preparation
procedures and instruments performance. However, some concerns has been
expressed regarding that hardness and abrasion behavior of acrylic resin and
dentin are not be identical . In this study extracted human teeth were
[45, 82]

used as a reproduction of the clinical situations.

The introduction of nickel titanium (Ni-Ti) rotary files to endodontics almost


two decades ago has changed the way of root canal preparations. These
rotary instruments has enabled practitioners to provide a more predictable
level of care to patients in a more timely and reproducible manner. It has
caused a paradigm shift in the way endodontic treatment is accomplished
and has raised the standard of care. The ProFile series has been set as the
gold standard among nickeltitanium rotary instrument against which others
are measured. Some investigations have reported that rotary NiTi
instruments do not clean root canal walls effectively, in particular the apical
part of curved canals[44, 61]. Additional concern has been expressed about the

85
comparatively high incidence of fractures of rotary nickeltitanium
[50]
instruments. On the other hand, Shaping of curved canals with stainless
steel K-files manipulated in a linear filing motion proved a satisfactory
method to maintain the original canal curvature.[17] Stainless steel files were
well known for creating aberrations in canals[31], but it appeared that their
propensity to create aberration is the result of their inherent stiffness of the
metal which is confounded by instruments design and canal shape . [33]

In this study, the time taken to prepare the canals with K-files was
significantly longer than that taken by the profile 0.04 taper. It was also
noted that longer time was taken for stainless steel K-files and rotary files to
prepare canals with 40o curvature. Many studies reported quicker preparation
time with rotary instruments than with hand instruments. [12, 68, 69]While other
studies have shown no difference.[63] It is likely that working time is more
dependent on operator factors and the preparation technique used rather than
the instruments themselves. Mesgouez et al reported that time required for
canal preparation with Profile was inversely related to operator experience,
the inexperienced operator demonstrated a significant linear regression
between canal number and preparation time occurred.[103] Over all, nickel
titanium rotary preparation is efficient to reduce patient and operator fatigue
whilst providing safe handling of instruments in the hand piece.[48]

Stainless steel K- files showed significantly higher incidences of instruments


failure, about 18 instruments were deformed and only 1 instrument showed
incident of fracture. Deformed K-file instruments were of various sizes i.e.
from size 10 up to size 50, This high deformity may be due to the low
modulus of elasticity of the material that makes it bend within canals.[69] The
Profile instruments showed failure in the form of fracture, only two

86
instruments (size 3,5) were fractured without prior evidence of plastic
[72]
deformation at the fifth use. Findings in this study were in contrast to
what was reported by Al-Omari et al[53] that the larger profiles size were
associated with more deformation than smaller files size contrary to what
was noted with stainless steel files. However, the low incidence of profile
instruments fractures was also reported by Defoire et al, who suggested its
continuous use in root canal treatment as well as the use by dental students
in laboratories if preventive methods are used.[42, 43]
Yared et al [79]

demonstrated that ProFile .04 instruments were safe to use without any
fracture with low-torque as well as with high-torque motors.

The importance of controlling the working length during root canal


treatment to avoid extrusion of debris through the apex, to maintain the
apical constriction, and to allow effective obturation of the canal system is
well known. In this study, there was an overall change in working distance
in both samples prepared by K-file hand instruments and Profile rotary
instruments and it was noted that loss of working distance was associated
with increased canal curvature. In previous study, Al-Omari reported that
with stainless steel hand instruments, length was lost as a result of a
combination of canal blockage, straightening of the canal and/or the creation
[64]
of aberrations such as ledges . This does not appear to be a common
problem with nickel-titanium rotary instruments as, despite potential
problems with operator control, there appears to be only limited change [10, 13,
48]
mostly in the form of over instrumentation and increase in working
distance as a result of lack of tactile sensation, certainly this was the case in
this study.

87
Intracanal impressions allowed a three dimensional assessment for canals
form. In general, the majority of canals prepared by both methods had apical
stops; there was no significant difference in the quality of apical stop
between samples prepared by hand K-files or by rotary profile instruments
Canals prepared with profiles showed better results for the quality of apical
and coronal smoothness than those prepared with k-files, Smooth canals and
adequate apical stops have been described with ProFile 0.04 Taper Series 29
instruments by Thompson & Dummer in 1997.[48] But in general, wall
smoothness was unsatisfactory for both systems. The same was applied to
flow characteristic of the canals, hence abrupt changes in the canals
direction was apparent in about half of the samples prepared with both
methods, which may be related to the operators inexperience.

Interestingly, there was a significant difference in canals taper between the


two methods, stainless steel K-files showed better taper qualities than
profiles in prepared canals. This may be due to previous reports that rotary
files tend to create slight canal transportation toward the outer aspect of the
[11, 62, 65]
curvature in the apical region of the canals. On the other hand, two
reports contradict the results of taper quality of Profiles in this study;
Nagratna reported that good taper quality was more significant using
Profiles.[69] Thompson reported that Profiles produced tapered preparation in
all of the specimens prepared in study and positive characteristics are
presumably a reflection of their planning action during rotation; such a
canal shape would appear to facilitate obturation.[48]

88
4.2 Conclusion:
Within the limitation of this in vitro study it was concluded that Profile0.04
series 29 rotary systems prepare canals more rapidly, and showed low
incidences of instruments failure in the form of fracture without creating
blockages, and only limited loss of working length. Canal preparation with
K-file was time consuming and showed higher incidence of deformed
instruments that was probably due to low elasticity of the stainless steel
metal that caused the file to permanently deform within the canal. Both
systems showed unsatisfactory results for canal walls smoothness and flow
but K-files showed better canal taper.

89
4.3 Recommendation:

1. To overcome problems associated with each preparation method, it is


recommended to combine both methods in a single preparation
technique. However, this would need to be further investigated.

2. Properties of Ni-Ti instruments have been derived from in vitro


studies on extracted teeth, and their claimed superiority with respect to
conventional stainless steel instruments need to be conclusively
clinically proven.

3. Dental schools in Sudan should implement the use of rotary systems


by undergraduate students after they master hand instruments and
techniques in root canal preparation.

4. Provision of Continuous educational programs in rotary instruments


to general practitioners and specialists to up their knowledge and to
improve skills.

90
5 CHAPTER FIVE - REFERENCE

91
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97
Appendix A

Data analysis results

98
Group Statistics

Std. Error
Type N Mean Std. Deviation Mean
Hand 1 34 602.24 214.801 36.838
2 34 441.26 184.848 31.701

Independent Samples Test

t-test for Equality of Means

Std. 95% Confidence


Mean Error Interval of the
Sig. Differe Differen Difference
t df (2-tailed) nce ce Lower Upper
Hand Equal variances
3.312 66 .002 160.97 48.600 63.937 258.00
assumed
Equal variances
3.312 64.57 .002 160.97 48.600 63.896 258.04
not assumed

Apicalstop * Type Crosstabulation

Type
Hand Rotary Total
Apicalstop Present 26 28 54
48.1% 51.9% 100.0%
Absent 8 6 14
57.1% 42.9% 100.0%
Total 34 34 68
50.0% 50.0% 100.0%

Chi-Square Tests

Asymp. Sig. Exact Sig. Exact Sig.


Value df (2-sided) (2-sided) (1-sided)
Pearson Chi-Square .360b 1 .549
Continuity Correctiona .090 1 .764
Likelihood Ratio .361 1 .548
Fisher's Exact Test .765 .383
Linear-by-Linear
.354 1 .552
Association
N of Valid Cases 68
a. Computed only for a 2x2 table
b. 0 cells (.0%) have expected count less than 5. The minimum expected count is 7.
00.

99
Apical Smoothness * Type Crosstabulation

Type
Hand Rotary Total
Smooth1 Good Count 12 15 27
% within Smooth1 44.4% 55.6% 100.0%
Poor Count 22 19 41
% within Smooth1 53.7% 46.3% 100.0%
Total Count 34 34 68
% within Smooth1 50.0% 50.0% 100.0%

Chi-Square Tests

Asymp. Sig. Exact Sig. Exact Sig.


Value df (2-sided) (2-sided) (1-sided)
Pearson Chi-Square .553b 1 .457
Continuity Correctiona .246 1 .620
Likelihood Ratio .554 1 .457
Fisher's Exact Test .621 .310
Linear-by-Linear
.545 1 .460
Association
N of Valid Cases 68
a. Computed only for a 2x2 table
b. 0 cells (.0%) have expected count less than 5. The minimum expected count is 13.
50.

Coronal Smoothness * Type Crosstabulation

Type
Hand Rotary Total
Smooth2 Good Count 20 23 43
% within Smooth2 46.5% 53.5% 100.0%
Poor Count 14 11 25
% within Smooth2 56.0% 44.0% 100.0%
Total Count 34 34 68
% within Smooth2 50.0% 50.0% 100.0%

100
Chi-Square Tests

Asymp. Sig. Exact Sig. Exact Sig.


Value df (2-sided) (2-sided) (1-sided)
Pearson Chi-Square .569b 1 .451
Continuity Correctiona .253 1 .615
Likelihood Ratio .570 1 .450
Fisher's Exact Test .615 .308
Linear-by-Linear
.561 1 .454
Association
N of Valid Cases 68
a. Computed only for a 2x2 table
b. 0 cells (.0%) have expected count less than 5. The minimum expected count is 12.
50.

Flow * Type Crosstabulation

Type
Hand Rotary Total
Flow Good Count 18 17 35
% within Flow 51.4% 48.6% 100.0%
Poor Count 16 17 33
% within Flow 48.5% 51.5% 100.0%
Total Count 34 34 68
% within Flow 50.0% 50.0% 100.0%

Chi-Square Tests

Asymp. Sig. Exact Sig. Exact Sig.


Value df (2-sided) (2-sided) (1-sided)
Pearson Chi-Square .059 b 1 .808
Continuity Correction a .000 1 1.000
Likelihood Ratio .059 1 .808
Fisher's Exact Test 1.000 .500
Linear-by-Linear
.058 1 .810
Association
N of Valid Cases 68
a. Computed only for a 2x2 table
b. 0 cells (.0%) have expected count less than 5. The minimum expected count is 16.
50.

101
Taper * Type Crosstabulation

Type
Hand Rotary Total
Taper Good Count 22 14 36
% within Taper 61.1% 38.9% 100.0%
Poor Count 12 20 32
% within Taper 37.5% 62.5% 100.0%
Total Count 34 34 68
% within Taper 50.0% 50.0% 100.0%

Chi-Square Tests

Asymp. Sig. Exact Sig. Exact Sig.


Value df (2-sided) (2-sided) (1-sided)
Pearson Chi-Square 3.778b 1 .052
Continuity Correctiona 2.892 1 .089
Likelihood Ratio 3.814 1 .051
Fisher's Exact Test .088 .044
Linear-by-Linear
3.722 1 .054
Association
N of Valid Cases 68
a. Computed only for a 2x2 table
b. 0 cells (.0%) have expected count less than 5. The minimum expected count is 16.
00.

102
InstrumentF * Type Crosstabulation

Type
Hand Rotary Total
InstrumentF Present Count 19 2 21
% within InstrumentF 90.5% 9.5% 100.0%
Absent Count 15 32 47
% within InstrumentF 31.9% 68.1% 100.0%
Total Count 34 34 68
% within InstrumentF 50.0% 50.0% 100.0%

Chi-Square Tests

Asymp. Sig. Exact Sig. Exact Sig.


Value df (2-sided) (2-sided) (1-sided)
Pearson Chi-Square 19.911b 1 .000
Continuity Correctiona 17.637 1 .000
Likelihood Ratio 22.194 1 .000
Fisher's Exact Test .000 .000
Linear-by-Linear
19.618 1 .000
Association
N of Valid Cases 68
a. Computed only for a 2x2 table
b. 0 cells (.0%) have expected count less than 5. The minimum expected count is 10.
50.

103
Appendix B

Working & recording


Sheets

104
Sample # # of curvature WL File Preparation MAF Loss Canal Instrument
canals angle/ Mm usage time of wl blockage failure
beginning #

105
Apical stop Smoothness smoothness Flow taper Horiz/ verti
apical coronal grooves
absent Present Present/ good Poor good poor Good poor good poor Absent present
/good poor

106

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